Healthcare Provider Details

I. General information

NPI: 1164425179
Provider Name (Legal Business Name): KEITH B MCDONALD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W CHARLESTON BLVD STE 103
LAS VEGAS NV
89146-1256
US

IV. Provider business mailing address

5701 W CHARLESTON BLVD STE 103
LAS VEGAS NV
89146-1256
US

V. Phone/Fax

Practice location:
  • Phone: 702-870-8485
  • Fax: 702-878-4907
Mailing address:
  • Phone: 702-870-8485
  • Fax: 702-878-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2393
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: