1245753300 NPI number — KEITH BROWN DMD, INC.

Table of content: (NPI 1245753300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245753300 NPI number — KEITH BROWN DMD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEITH BROWN DMD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1245753300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUCEDALE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39452-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-947-1219
Provider Business Mailing Address Fax Number:
601-947-9461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCEDALE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39452-6180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-947-1219
Provider Business Practice Location Address Fax Number:
601-947-9461
Provider Enumeration Date:
07/20/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
ABRAM
Authorized Official Title or Position:
OWNER /DENTIST
Authorized Official Telephone Number:
601-947-1219

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3948-17 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 2663-92D , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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