Provider Demographics
NPI:1134297229
Name:VON BOECKMANN, KEITH J (DDS, FAGD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:VON BOECKMANN
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7435 SOUTH HWY 6
Mailing Address - Street 2:SUITE A
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459
Mailing Address - Country:US
Mailing Address - Phone:281-499-7645
Mailing Address - Fax:281-499-6730
Practice Address - Street 1:7435 SOUTH HWY 6
Practice Address - Street 2:SUITE A
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459
Practice Address - Country:US
Practice Address - Phone:281-499-7645
Practice Address - Fax:281-499-6730
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice