Provider Demographics
NPI:1154473049
Name:STUMMER, KEITH A (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:STUMMER
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 1:4467 114TH ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-3860
Mailing Address - Country:US
Mailing Address - Phone:262-764-0368
Mailing Address - Fax:
Practice Address - Street 1:3100 80TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4946
Practice Address - Country:US
Practice Address - Phone:262-694-2961
Practice Address - Fax:262-942-7340
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35560151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice