MEDICARE: DR. KEENAN R DECKER 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	3041	AR

General Provider Information

NPI Number	:	1902971708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEENAN R DECKER D.M.D.

Provider Business Mailing Address
First Line	:	3608 SOUTHERN HILLS BLVD
Second Line	:	SUITE 2
City	:	ROGERS
State	:	AR
Zip	:	72758-8013
Country	:	US
Telephone Number	:	479-659-0900
Fax Number	:	479-659-0902

Provider Business Practice Location Address
First Line	:	3608 SOUTHERN HILLS BLVD
Second Line	:	SUITE 2
City	:	ROGERS
State	:	AR
Zip	:	72758-8013
Country	:	US
Telephone Number	:	479-659-0900
Fax Number	:	479-659-0902

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	02/03/2009

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