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General NPI Number Information
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NPI Number | 1114339868
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Entity Type | Individual
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Provider Name | WILLIAM BLAKE KEASTER D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 05/29/2014
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Provider Practice Location Address
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Address Line | 540 W LASALLE ST
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City | SPRINGFIELD
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State | MO
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Zip | 65807-4712
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Country | US
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Telephone | 417-887-1220
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Fax | 417-887-0357
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Provider Business Mailing Address
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Address Line | 3124 W SEXTON ST
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City | SPRINGFIELD
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State | MO
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Zip | 65810-1297
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Country | US
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Telephone | 870-421-6820
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2014015938
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License Number State | MO
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