Provider Demographics
NPI:1073601506
Name:KEANNA, GEORGE ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ALBERT
Last Name:KEANNA
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 1:1100 LEAD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-5215
Mailing Address - Country:US
Mailing Address - Phone:505-797-5549
Mailing Address - Fax:
Practice Address - Street 1:1100 LEAD AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5215
Practice Address - Country:US
Practice Address - Phone:505-292-8533
Practice Address - Fax:505-292-2712
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist