Provider Demographics
NPI:1376751347
Name:NORWALK, KEITH ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:NORWALK
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 1:103 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1701
Mailing Address - Country:US
Mailing Address - Phone:419-855-4700
Mailing Address - Fax:
Practice Address - Street 1:103 W 5TH ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1701
Practice Address - Country:US
Practice Address - Phone:419-855-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0151553Medicaid
OH9199924OtherDORAL