Provider Demographics
NPI:1417917584
Name:NOWICKI, KEITH DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DAVID
Last Name:NOWICKI
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 1:32545 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-3843
Mailing Address - Country:US
Mailing Address - Phone:586-293-3633
Mailing Address - Fax:586-293-5683
Practice Address - Street 1:32545 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-3843
Practice Address - Country:US
Practice Address - Phone:586-293-3633
Practice Address - Fax:586-293-5683
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI173311223G0001X
MI2901017331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI973959OtherUNITED CONCORDIA MILITARY