=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902971708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEENAN R DECKER D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 02/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3608 SOUTHERN HILLS BLVD SUITE 2
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-659-0900
-----------------------------------------------------
Fax | 479-659-0902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3608 SOUTHERN HILLS BLVD SUITE 2
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-659-0900
-----------------------------------------------------
Fax | 479-659-0902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3041
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------