Healthcare Provider Details

I. General information

NPI: 1891786224
Provider Name (Legal Business Name): THOMAS MAURICE KEANE JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 PENN AVE SO. SUITE 211
BLOOMINGTON MN
55431
US

IV. Provider business mailing address

8900 PENN AVE SO. SUITE 211
BLOOMINGTON MN
55431
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-3844
  • Fax: 952-920-3008
Mailing address:
  • Phone: 952-920-3844
  • Fax: 952-920-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number9671
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: