Provider Demographics
NPI:1821233222
Name:DOTY, KEITH W (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:DOTY
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 1:12540 SW 68TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8597
Mailing Address - Country:US
Mailing Address - Phone:503-620-5313
Mailing Address - Fax:
Practice Address - Street 1:12540 SW 68TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8597
Practice Address - Country:US
Practice Address - Phone:503-620-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-14
Last Update Date:2008-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist