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General NPI Number Information
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NPI Number | 1629602065
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Entity Type | Individual
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Provider Name | KEITH WILLIAM STREET DMD
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Gender | Male
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Dates
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Enumeration Date | 02/25/2020
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Last Update Date | 02/25/2020
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Provider Practice Location Address
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Address Line | 1460 JOHN B WHITE SR BLVD STE 1-5
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City | SPARTANBURG
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State | SC
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Zip | 29306-3996
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Country | US
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Telephone | 470-552-1823
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Fax |
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Provider Business Mailing Address
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Address Line | 1460 JOHN B WHITE SR BLVD STE 1-5
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City | SPARTANBURG
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State | SC
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Zip | 29306-3996
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Country | US
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Telephone |
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2984
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License Number State | SC
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