Provider Demographics
NPI:1528041605
Name:NALLEY, KEITH A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:NALLEY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 S BEECHTREE ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2384
Mailing Address - Country:US
Mailing Address - Phone:616-844-5135
Mailing Address - Fax:616-844-5181
Practice Address - Street 1:919 S BEECHTREE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2384
Practice Address - Country:US
Practice Address - Phone:616-844-5135
Practice Address - Fax:616-844-5181
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901014734OtherSTATE LICENSE #
MI2901014734OtherSTATE LICENSE #
MI0G06047Medicare ID - Type Unspecified