Provider Demographics
NPI:1922087428
Name:MATHENY, KEITH WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WAYNE
Last Name:MATHENY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10803 SE KENT KANGLEY RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7194
Mailing Address - Country:US
Mailing Address - Phone:253-859-0658
Mailing Address - Fax:253-859-8052
Practice Address - Street 1:10803 SE KENT KANGLEY RD
Practice Address - Street 2:SUITE #100
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7194
Practice Address - Country:US
Practice Address - Phone:253-859-0658
Practice Address - Fax:253-859-8052
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA55961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA56326OtherLABOR & INDUSTRIES
WA5001581OtherDSHS