Provider Demographics
NPI:1174887863
Name:BRACY, KEITH EMANUEL (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:EMANUEL
Last Name:BRACY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 12TH ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8241
Mailing Address - Country:US
Mailing Address - Phone:212-390-8399
Mailing Address - Fax:509-275-3412
Practice Address - Street 1:100 W 12TH ST APT 1D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-390-8399
Practice Address - Fax:509-275-3412
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist