=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376825083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS KEENAN MILLSTEAD D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2011
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 RANDOLPH
-----------------------------------------------------
City | FORT SILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-413-1635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | USA DENTAL HEALTH ACTIVITY 506 RANDOLPH RD
-----------------------------------------------------
City | FORT SILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 27162
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 027162
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 27162
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------