Provider Demographics
NPI:1770584500
Name:KEAVENY, JOHN TENNIS (DDS OMS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TENNIS
Last Name:KEAVENY
Suffix:
Gender:M
Credentials:DDS OMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 12TH ST W
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3554
Mailing Address - Country:US
Mailing Address - Phone:701-225-5163
Mailing Address - Fax:701-264-1032
Practice Address - Street 1:669 12TH ST W
Practice Address - Street 2:SUITE 2
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3554
Practice Address - Country:US
Practice Address - Phone:701-225-5163
Practice Address - Fax:701-264-1032
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41384Medicaid
ND931444Medicare ID - Type Unspecified
ND931444Medicare ID - Type Unspecified