Provider Demographics
NPI:1578655767
Name:KEEL, M BERT JR (DMD)
Entity type:Individual
Prefix:DR
First Name:M
Middle Name:BERT
Last Name:KEEL
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-4538
Mailing Address - Country:US
Mailing Address - Phone:228-467-5577
Mailing Address - Fax:228-467-0468
Practice Address - Street 1:304 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-4538
Practice Address - Country:US
Practice Address - Phone:228-467-5577
Practice Address - Fax:228-467-0468
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1933-81122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640701713OtherTAX IDENTIFICATION NUMBER