Healthcare Provider Details

I. General information

NPI: 1841736634
Provider Name (Legal Business Name): DMITRY KEYSALOV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7017 SW NYBERG ST
TUALATIN OR
97062-6243
US

IV. Provider business mailing address

6682 SW BRISBAND ST
WILSONVILLE OR
97070-6905
US

V. Phone/Fax

Practice location:
  • Phone: 503-612-8736
  • Fax:
Mailing address:
  • Phone: 757-995-6725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11923
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: