Provider Demographics
NPI:1154847622
Name:ALEX KEITH, DMD, DENTAL CORPORATION
Entity Type:Organization
Organization Name:ALEX KEITH, DMD, DENTAL CORPORATION
Other - Org Name:ONE LOOSE TOOTH, DENTAL PRACTICE OF DR. ALEX KEITH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:510-912-0923
Mailing Address - Street 1:4330 GOLDEN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6232
Mailing Address - Country:US
Mailing Address - Phone:530-642-8614
Mailing Address - Fax:530-642-9314
Practice Address - Street 1:4330 GOLDEN CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6232
Practice Address - Country:US
Practice Address - Phone:530-642-8614
Practice Address - Fax:530-642-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100100261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental