MEDICARE: KEITH S QUINN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6931	OK

General Provider Information

NPI Number	:	1134643380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH S QUINN DDS

Provider Business Mailing Address
First Line	:	351 W 6TH STREET
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31314-5641
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3008 PEACEFUL LN
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034
Country	:	US
Telephone Number	:	405-219-6537
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2017
Last Update Date	:	11/13/2019

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