Healthcare Provider Details

I. General information

NPI: 1962404301
Provider Name (Legal Business Name): CHRISTOPHER TIMOTHY KEENAN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 STOCKADE RD
SUMMERVILLE GA
30747-1900
US

IV. Provider business mailing address

810 RIVER RUSH DR
SUGAR HILL GA
30518-7462
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-2323
  • Fax: 706-857-7041
Mailing address:
  • Phone: 770-826-7710
  • Fax: 706-857-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN013152
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013152
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: