Provider Demographics
NPI:1518031053
Name:GRESSELL, KEITH MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MICHAEL
Last Name:GRESSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 402
Mailing Address - Street 2:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Mailing Address - City:APO AE
Mailing Address - State:NY
Mailing Address - Zip Code:09227
Mailing Address - Country:US
Mailing Address - Phone:631-350-7524
Mailing Address - Fax:
Practice Address - Street 1:CMR 402
Practice Address - Street 2:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Practice Address - City:APO AE
Practice Address - State:NY
Practice Address - Zip Code:09227
Practice Address - Country:US
Practice Address - Phone:631-350-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist