Provider Demographics
NPI:1558401505
Name:CHURCHILL, KEITH ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:CHURCHILL
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 1:6530 31ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-2429
Mailing Address - Country:US
Mailing Address - Phone:507-288-1784
Mailing Address - Fax:
Practice Address - Street 1:615 16TH ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2123
Practice Address - Country:US
Practice Address - Phone:507-288-2539
Practice Address - Fax:507-288-9230
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6951D1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice