Provider Demographics
NPI:1497920573
Name:KEENAN R. DECKER D.M.D.
Entity Type:Organization
Organization Name:KEENAN R. DECKER D.M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:479-770-4333
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-1037
Mailing Address - Country:US
Mailing Address - Phone:479-770-4333
Mailing Address - Fax:479-770-4334
Practice Address - Street 1:1815 BILLIE ACRES PL
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8641
Practice Address - Country:US
Practice Address - Phone:479-770-4333
Practice Address - Fax:479-770-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S900OtherBLUE CROSS BLUE SHIELD