Provider Demographics
NPI:1124917794
Name:KEOUGH, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KEOUGH
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SAMS RD
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ME
Mailing Address - Zip Code:04258-5035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 MAIN ST, EAST WILTON
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:ME
Practice Address - Zip Code:04234
Practice Address - Country:US
Practice Address - Phone:207-645-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN52561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice