Healthcare Provider Details

I. General information

NPI: 1225703309
Provider Name (Legal Business Name): DAVID KEENS-DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6820 PARK PL SUITE 117
INDIANAPOLIS IN
46254
US

IV. Provider business mailing address

6820 PARK PL SUITE 117
INDIANAPOLIS IN
46254
US

V. Phone/Fax

Practice location:
  • Phone: 317-329-7373
  • Fax:
Mailing address:
  • Phone: 317-329-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12013695A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: