Healthcare Provider Details

I. General information

NPI: 1578614640
Provider Name (Legal Business Name): KEVIN KEITH KEEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 MISSION PARK DR
VICKSBURG MS
39180-3747
US

IV. Provider business mailing address

1205 MISSION PARK DR
VICKSBURG MS
39180-3747
US

V. Phone/Fax

Practice location:
  • Phone: 601-661-0034
  • Fax: 601-661-0367
Mailing address:
  • Phone: 601-661-0034
  • Fax: 601-661-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1223S0112X
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: