MEDICARE: KEISI IKONOMI DMD

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	1223G0001X	General Practice Dentistry	DEN03679	RI

General Provider Information

NPI Number	:	1164103339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISI IKONOMI DMD

Provider Business Mailing Address
First Line	:	134 MORELAND RD
Second Line	:
City	:	N WEYMOUTH
State	:	MA
Zip	:	02191-1738
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2148 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02911-1722
Country	:	US
Telephone Number	:	401-622-6080
Fax Number	:

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

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	07/31/2023

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