Provider Demographics
NPI:1124138771
Name:MACDONALD, KEITH THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:THOMAS
Last Name:MACDONALD
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 1:3804 GASTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-7759
Mailing Address - Country:US
Mailing Address - Phone:336-294-1549
Mailing Address - Fax:336-434-3189
Practice Address - Street 1:9924 US HIGHWAY 311
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-8826
Practice Address - Country:US
Practice Address - Phone:336-434-3186
Practice Address - Fax:336-434-3189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice