Provider Demographics
NPI:1649304361
Name:WADE, KEITH (DMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WADE
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 1:101 MAIN ST S
Mailing Address - Street 2:BOX 640
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-2032
Mailing Address - Country:US
Mailing Address - Phone:203-266-7435
Mailing Address - Fax:203-266-5100
Practice Address - Street 1:101 MAIN ST S
Practice Address - Street 2:BOX 640
Practice Address - City:BETHLEHEM
Practice Address - State:CT
Practice Address - Zip Code:06751-2032
Practice Address - Country:US
Practice Address - Phone:203-266-7435
Practice Address - Fax:203-266-5100
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT73501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice