Provider Demographics
NPI:1154462745
Name:KECK, BLAIR A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:A
Last Name:KECK
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 1:4128 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2408
Mailing Address - Country:US
Mailing Address - Phone:415-863-9255
Mailing Address - Fax:415-863-9082
Practice Address - Street 1:4128 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-2408
Practice Address - Country:US
Practice Address - Phone:415-863-9255
Practice Address - Fax:415-863-9082
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS356231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice