=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710304399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A KEELER FAMILY DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2014
-----------------------------------------------------
Last Update Date | 03/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 E RICHARDS STREET
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-358-1720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 E RICHARDS STREET
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-358-1720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MS. ALEXANDRA KEELER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 307-358-1720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1315
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------