Provider Demographics
NPI:1619131497
Name:KEAN, DON CHARLES (DMD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:CHARLES
Last Name:KEAN
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 1:2410 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1539
Mailing Address - Country:US
Mailing Address - Phone:502-778-5141
Mailing Address - Fax:
Practice Address - Street 1:2410 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1539
Practice Address - Country:US
Practice Address - Phone:502-778-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6182122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061827Medicaid