Provider Demographics
NPI:1700174299
Name:DOUTS, KEITH BRIAN JR (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRIAN
Last Name:DOUTS
Suffix:JR
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:6920 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2206
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-844-9006
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011663A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201032760Medicaid