Provider Demographics
NPI:1871612507
Name:BAINES, KEITH (DMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BAINES
Suffix:
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 1:386 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307
Mailing Address - Country:US
Mailing Address - Phone:201-659-5030
Mailing Address - Fax:
Practice Address - Street 1:386 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-659-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0198091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice