Provider Demographics
NPI:1578927786
Name:FORRESTER, KEATON (DMD)
Entity Type:Individual
Prefix:
First Name:KEATON
Middle Name:
Last Name:FORRESTER
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 1:375 MDG 310 WEST LOSEY
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5252
Mailing Address - Country:US
Mailing Address - Phone:618-256-6667
Mailing Address - Fax:
Practice Address - Street 1:375 MDG 310 WEST LOSEY
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5252
Practice Address - Country:US
Practice Address - Phone:618-256-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85691223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice