Provider Demographics
NPI:1396976981
Name:STEVENER, KEITH ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ANDREW
Last Name:STEVENER
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 1:527 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1536
Practice Address - Country:US
Practice Address - Phone:315-637-8213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50054495122300000X
NMTD-00-21122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist