Provider Demographics
NPI:1225703309
Name:KEENS-DOUGLAS, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KEENS-DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51100 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6705
Mailing Address - Country:US
Mailing Address - Phone:754-252-8750
Mailing Address - Fax:
Practice Address - Street 1:4024 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5807
Practice Address - Country:US
Practice Address - Phone:574-538-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013695A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist