Provider Demographics
NPI:1225258676
Name:BROWN, KEITH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:BROWN
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:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-0006
Mailing Address - Country:US
Mailing Address - Phone:601-947-1219
Mailing Address - Fax:601-947-9461
Practice Address - Street 1:16 PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:601-947-1219
Practice Address - Fax:601-947-9461
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2663 92D1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660013Medicaid