Provider Demographics
NPI:1164638383
Name:FINCANNON, KEITH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:FINCANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 RABBIT ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:SC
Mailing Address - Zip Code:29563-5362
Mailing Address - Country:US
Mailing Address - Phone:843-759-0175
Mailing Address - Fax:843-774-7920
Practice Address - Street 1:101 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2421
Practice Address - Country:US
Practice Address - Phone:843-774-7762
Practice Address - Fax:843-774-7920
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ32108Medicaid
NC8992681Medicaid