Provider Demographics
NPI:1730757048
Name:HUGHES, KEATON WALLACE (DMD)
Entity type:Individual
Prefix:
First Name:KEATON
Middle Name:WALLACE
Last Name:HUGHES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KEATON
Other - Middle Name:LARSON
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9266 CRESCENT LODGE CIR
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-2583
Mailing Address - Country:US
Mailing Address - Phone:770-807-5726
Mailing Address - Fax:
Practice Address - Street 1:7065 FAIN PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7862
Practice Address - Country:US
Practice Address - Phone:334-279-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006892-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty