Provider Demographics
NPI:1609915412
Name:RADACK, KEITH L (DR)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:L
Last Name:RADACK
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
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Mailing Address - Street 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-845-2616
Mailing Address - Fax:818-845-3359
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-845-2616
Practice Address - Fax:818-845-3359
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAD230241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery