Provider Demographics
NPI:1568676310
Name:JOHN T. KEAVENY, DDS
Entity Type:Organization
Organization Name:JOHN T. KEAVENY, DDS
Other - Org Name:ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TEUNIS
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-225-5163
Mailing Address - Street 1:669 12TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3554
Mailing Address - Country:US
Mailing Address - Phone:701-225-5163
Mailing Address - Fax:701-264-1032
Practice Address - Street 1:669 12TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3554
Practice Address - Country:US
Practice Address - Phone:701-225-5163
Practice Address - Fax:701-264-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41384Medicaid
ND26747OtherBCBS MEDICAL
ND949318OtherDSC DENTAL
ND26747OtherBCBS MEDICAL