Provider Demographics
NPI:1902843683
Name:KECK, ROBERT J (DDS, MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:KECK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 VETERANS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3410
Mailing Address - Country:US
Mailing Address - Phone:320-252-3611
Mailing Address - Fax:320-252-7574
Practice Address - Street 1:3950 VETERANS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3410
Practice Address - Country:US
Practice Address - Phone:320-252-3611
Practice Address - Fax:320-252-7574
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND83321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN242820200Medicaid
MN859000021Medicare ID - Type Unspecified
MN242820200Medicaid