1215294848 NPI number — ROBERT RICHARD KEEN DDS

Table of content: ROBERT RICHARD KEEN DDS (NPI 1215294848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215294848 NPI number — ROBERT RICHARD KEEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEEN
Provider First Name:
ROBERT
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215294848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1915 WEST PARK DRIVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
NORTH WILKESBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28659-3777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-667-5170
Provider Business Mailing Address Fax Number:
336-903-7313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 WEST PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE #104
Provider Business Practice Location Address City Name:
NORTH WILKESBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28659-3777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-667-5170
Provider Business Practice Location Address Fax Number:
336-903-7313
Provider Enumeration Date:
04/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  #150870 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FK3001675 . This is a "BNDD" identifier . This identifiers is of the category "OTHER".




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