Provider Demographics
NPI:1437137643
Name:RAE, KEITH WILLIAM (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WILLIAM
Last Name:RAE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CROSS ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1670
Mailing Address - Country:US
Mailing Address - Phone:978-741-9004
Mailing Address - Fax:
Practice Address - Street 1:39 CROSS ST
Practice Address - Street 2:SUITE 109
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-1670
Practice Address - Country:US
Practice Address - Phone:978-741-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74679208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3081150Medicaid
E99797Medicare UPIN
MAJ11621Medicare ID - Type Unspecified