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General NPI Number Information
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NPI Number | 1841736634
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Entity Type | Individual
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Provider Name | DMITRY KEYSALOV DDS
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Gender | Male
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 7017 SW NYBERG ST
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City | TUALATIN
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State | OR
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Zip | 97062-6243
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Country | US
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Telephone | 503-612-8736
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Fax |
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Provider Business Mailing Address
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Address Line | 6682 SW BRISBAND ST
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City | WILSONVILLE
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State | OR
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Zip | 97070-6905
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Country | US
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Telephone | 757-995-6725
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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 | D11923
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License Number State | OR
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