Provider Demographics
NPI:1780352260
Name:FOSTER, KEITH ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1485
Mailing Address - Country:US
Mailing Address - Phone:920-380-4055
Mailing Address - Fax:920-380-4056
Practice Address - Street 1:1111 W VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1485
Practice Address - Country:US
Practice Address - Phone:920-380-4055
Practice Address - Fax:920-380-4056
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002679-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice