Provider Demographics
NPI:1184755092
Name:MANN, KEITH W (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:W
Last Name:MANN
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 1:818-101 PINE GROVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409
Mailing Address - Country:US
Mailing Address - Phone:910-397-9277
Mailing Address - Fax:910-397-9137
Practice Address - Street 1:818-101 PINE GROVE DRIVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409
Practice Address - Country:US
Practice Address - Phone:910-397-9277
Practice Address - Fax:910-397-9137
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC523057OtherUNITED CONCORDIA
NC95504OtherBLUE CROSS BLUE SHIELD
NC8995504Medicaid