Provider Demographics
NPI:1619574688
Name:KEEN, BRYCE MARK (DDS)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:MARK
Last Name:KEEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5029 LOMAS CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-1542
Mailing Address - Country:US
Mailing Address - Phone:909-714-7105
Mailing Address - Fax:
Practice Address - Street 1:9606 BASELINE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5035
Practice Address - Country:US
Practice Address - Phone:909-989-6661
Practice Address - Fax:909-989-6663
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1056391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice