Healthcare Provider Details

I. General information

NPI: 1699419150
Provider Name (Legal Business Name): KEITH EARL JANUARY JR. MS, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 N FRANKLIN ST
BASTROP LA
71220-3846
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-283-8887
  • Fax: 318-281-6339
Mailing address:
  • Phone: 318-283-8887
  • Fax: 318-281-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7359
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: