Healthcare Provider Details

I. General information

NPI: 1902843683
Provider Name (Legal Business Name): ROBERT J KECK D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 VETERANS DR SUITE 100
SAINT CLOUD MN
56303-3410
US

IV. Provider business mailing address

3950 VETERANS DR SUITE 100
SAINT CLOUD MN
56303-3410
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-3611
  • Fax: 320-252-7574
Mailing address:
  • Phone: 320-252-3611
  • Fax: 320-252-7574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD8332
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: