Provider Demographics
NPI:1013241025
Name:M. BERT KEEL JR DMD PA
Entity Type:Organization
Organization Name:M. BERT KEEL JR DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:BERT
Authorized Official - Last Name:KEEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-467-5577
Mailing Address - Street 1:304 N SECOND ST
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-4538
Mailing Address - Country:US
Mailing Address - Phone:228-467-5577
Mailing Address - Fax:228-467-0468
Practice Address - Street 1:304 N SECOND ST
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-4538
Practice Address - Country:US
Practice Address - Phone:228-467-5577
Practice Address - Fax:228-467-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1933811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty