Provider Demographics
NPI:1780792515
Name:POE, KEITH WAYNE (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:POE
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 1:3200 SUNBURST DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707
Mailing Address - Country:US
Mailing Address - Phone:432-694-8823
Mailing Address - Fax:432-694-8825
Practice Address - Street 1:3200 SUNBURST DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707
Practice Address - Country:US
Practice Address - Phone:432-694-8823
Practice Address - Fax:432-694-8825
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX127581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice