Healthcare Provider Details

I. General information

NPI: 1710006945
Provider Name (Legal Business Name): MICHAEL L KEIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 23RD AVE S SUITE B
FARGO ND
58103-6172
US

IV. Provider business mailing address

2585 23RD AVE S SUITE B
FARGO ND
58103-6172
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-0006
  • Fax: 701-293-7724
Mailing address:
  • Phone: 701-293-0006
  • Fax: 701-293-7724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1784
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: