Healthcare Provider Details

I. General information

NPI: 1871745901
Provider Name (Legal Business Name): KEITH FUSAO OGAWA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W. MAIN ST.
EAGLE POINT OR
97524
US

IV. Provider business mailing address

P.O. BOX 236 217 W. MAIN ST.
EAGLE POINT OR
97524
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2525
  • Fax: 541-826-2876
Mailing address:
  • Phone: 541-826-2525
  • Fax: 541-826-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6945
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: