Provider Demographics
NPI:1083876031
Name:KEISTER, BLAINE (DMD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:KEISTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2407
Mailing Address - Country:US
Mailing Address - Phone:732-946-4244
Mailing Address - Fax:732-946-4492
Practice Address - Street 1:146 ROUTE 34
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-2407
Practice Address - Country:US
Practice Address - Phone:732-946-4244
Practice Address - Fax:732-946-4492
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI025860001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice