MEDICARE: DR. DUONGVANNAK J KEO D.M.D.

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	13955	FL

General Provider Information

NPI Number	:	1861571556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DUONGVANNAK J KEO D.M.D.

Provider Business Mailing Address
First Line	:	295 S PLUMOSA ST
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3525
Country	:	US
Telephone Number	:	321-452-6000
Fax Number	:	321-453-8823

Provider Business Practice Location Address
First Line	:	295 S PLUMOSA
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-4886
Country	:	US
Telephone Number	:	321-452-6000
Fax Number	:	321-453-8823

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	03/09/2010

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