Provider Demographics
NPI:1821134354
Name:LOWRY, KEITH W
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:LOWRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-867-8011
Mailing Address - Fax:804-866-9043
Practice Address - Street 1:210 S WILLOW ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-867-8011
Practice Address - Fax:804-866-9043
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995405Medicaid
NC8995405Medicaid