Healthcare Provider Details

I. General information

NPI: 1023085305
Provider Name (Legal Business Name): KEITH E. MCDONALD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 DUVALL AVE NE SUITE 140
RENTON WA
98059-4675
US

IV. Provider business mailing address

451 DUVALL AVE NE SUITE 140
RENTON WA
98059-4675
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-5437
  • Fax: 425-663-7990
Mailing address:
  • Phone: 425-228-5437
  • Fax: 425-663-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE00010042
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: