Provider Demographics
NPI:1700902574
Name:SPROUT, BEVERLY KEELER (DDS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:KEELER
Last Name:SPROUT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32581 MEADOW MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9731
Mailing Address - Country:US
Mailing Address - Phone:303-674-3542
Mailing Address - Fax:
Practice Address - Street 1:31226 LEWIS RIDGE RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7998
Practice Address - Country:US
Practice Address - Phone:303-674-5566
Practice Address - Fax:303-674-8911
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice