Provider Demographics
NPI:1376678482
Name:BOENNING, KEITH A (DDS, LLC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:BOENNING
Suffix:
Gender:M
Credentials:DDS, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 KENILWORTH DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2101
Mailing Address - Country:US
Mailing Address - Phone:410-828-1717
Mailing Address - Fax:410-821-0912
Practice Address - Street 1:1104 KENILWORTH DR
Practice Address - Street 2:SUITE 104
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2101
Practice Address - Country:US
Practice Address - Phone:410-828-1717
Practice Address - Fax:410-821-0912
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD82571223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD26-2579369OtherFEDERAL TAX ID