Provider Demographics
NPI:1811299910
Name:KEITH DOTY DDS LLC
Entity type:Organization
Organization Name:KEITH DOTY DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-620-5313
Mailing Address - Street 1:12540 SW 68TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8597
Mailing Address - Country:US
Mailing Address - Phone:503-620-5313
Mailing Address - Fax:503-620-5497
Practice Address - Street 1:12540 SW 68TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8597
Practice Address - Country:US
Practice Address - Phone:503-620-5313
Practice Address - Fax:503-620-5497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty