Provider Demographics
NPI:1164103339
Name:IKONOMI, KEISI (DMD)
Entity Type:Individual
Prefix:
First Name:KEISI
Middle Name:
Last Name:IKONOMI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MORELAND RD
Mailing Address - Street 2:
Mailing Address - City:N WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02191-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2148 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-1722
Practice Address - Country:US
Practice Address - Phone:401-622-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN036791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice