Provider Demographics
NPI:1477605442
Name:KEADLE, JOHN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SCOTT
Last Name:KEADLE
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 1:18204 MAINSAIL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5198
Mailing Address - Country:US
Mailing Address - Phone:704-650-0249
Mailing Address - Fax:
Practice Address - Street 1:118 GATEWAY BLVD STE A
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6542
Practice Address - Country:US
Practice Address - Phone:704-639-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice