Provider Demographics
NPI:1487756250
Name:KEITH, KELLY WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:WAYNE
Last Name:KEITH
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 1:4201 NORTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-342-9697
Mailing Address - Fax:512-452-7365
Practice Address - Street 1:3800 SPEEDWAY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751
Practice Address - Country:US
Practice Address - Phone:512-452-6405
Practice Address - Fax:512-452-7365
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist