Provider Demographics
NPI:1659626448
Name:GARY KEELER DDS, ORAL MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:GARY KEELER DDS, ORAL MAXILLOFACIAL SURGERY LLC
Other - Org Name:GARY KEELER DDS, ORAL MAXILLOFACIAL SURGERY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEELER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-936-3555
Mailing Address - Street 1:1060 E COUNTY LINE RD STE 3A-213
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1900
Mailing Address - Country:US
Mailing Address - Phone:601-936-3555
Mailing Address - Fax:601-936-3580
Practice Address - Street 1:1000 LAKELAND SQUARE EXT STE 700
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7648
Practice Address - Country:US
Practice Address - Phone:601-936-3555
Practice Address - Fax:601-936-3580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3478081223S0112X
261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01880393Medicaid