Provider Demographics
NPI:1013564442
Name:MESIDOR, KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:MESIDOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 IRVING ST NW
Mailing Address - Street 2:DENTAL CLINIC
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20422-0001
Mailing Address - Country:US
Mailing Address - Phone:202-745-8000
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-6257
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014169511223G0001X
390200000X
MD169521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program