Provider Demographics
NPI:1578614640
Name:KEEN, KEVIN KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:KEITH
Last Name:KEEN
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 1:1205 MISSION PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3747
Mailing Address - Country:US
Mailing Address - Phone:601-661-0034
Mailing Address - Fax:601-661-0367
Practice Address - Street 1:1205 MISSION PARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3747
Practice Address - Country:US
Practice Address - Phone:601-661-0034
Practice Address - Fax:601-661-0367
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223S0112X1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU80152Medicare UPIN