Provider Demographics
NPI:1114098340
Name:COLWELL, KEITH ALLAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLAN
Last Name:COLWELL
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 1:9513 NW NEWGATE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2959
Mailing Address - Country:US
Mailing Address - Phone:515-986-3489
Mailing Address - Fax:
Practice Address - Street 1:6057 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1704
Practice Address - Country:US
Practice Address - Phone:515-285-4759
Practice Address - Fax:515-287-2948
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA55591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7005942Medicaid
IA6005942Medicaid