1285815589 NPI number — GARY DEMETRICK KEELER DDS

Table of content: GARY DEMETRICK KEELER DDS (NPI 1285815589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285815589 NPI number — GARY DEMETRICK KEELER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEELER
Provider First Name:
GARY
Provider Middle Name:
DEMETRICK
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:
1285815589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 E COUNTY LINE RD STE 3A-213
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 LAKELAND SQUARE EXT STE 700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-936-3555
Provider Business Practice Location Address Fax Number:
601-936-3580
Provider Enumeration Date:
11/15/2007

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:  3478 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 8114 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01880393 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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