Provider Demographics
NPI:1194865246
Name:WATKINS, KEITH V (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:V
Last Name:WATKINS
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 1:215 HALLOCK RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3078
Mailing Address - Country:US
Mailing Address - Phone:631-689-3226
Mailing Address - Fax:631-689-3155
Practice Address - Street 1:215 HALLOCK RD
Practice Address - Street 2:SUITE 2
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3078
Practice Address - Country:US
Practice Address - Phone:631-689-3226
Practice Address - Fax:631-689-3155
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02630335Medicaid