Provider Demographics
NPI:1821024449
Name:ESKANOS, KEITH (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:ESKANOS
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 1:3103 CLEARWATER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7165
Mailing Address - Country:US
Mailing Address - Phone:928-237-6456
Mailing Address - Fax:928-777-3209
Practice Address - Street 1:3103 CLEARWATER DR
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7165
Practice Address - Country:US
Practice Address - Phone:928-237-6456
Practice Address - Fax:928-777-3209
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ920315Medicaid
AZAZ0415100OtherBLUE CROSS BLUE SHIELD