Provider Demographics
NPI:1851774293
Name:BOREN, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BOREN
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 1:101 S ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-3625
Mailing Address - Country:US
Mailing Address - Phone:918-825-7111
Mailing Address - Fax:
Practice Address - Street 1:101 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-3625
Practice Address - Country:US
Practice Address - Phone:918-825-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist