Provider Demographics
NPI:1578804167
Name:KEITH, DANIEL JAMES (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:KEITH
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 1:3906 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-8857
Mailing Address - Country:US
Mailing Address - Phone:701-471-5671
Mailing Address - Fax:
Practice Address - Street 1:4401 COLEMAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1370
Practice Address - Country:US
Practice Address - Phone:701-471-5671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40839Medicaid