=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811039258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDY PAUL KEATON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 10/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 384 N MAYO TRL UNIT A
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41501-1493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-432-8165
-----------------------------------------------------
Fax | 606-437-1085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 989
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-432-8165
-----------------------------------------------------
Fax | 606-437-1085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 6480
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------