Provider Demographics
NPI:1871745901
Name:OGAWA, KEITH FUSAO (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:FUSAO
Last Name:OGAWA
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:P.O. BOX 236
Mailing Address - Street 2:217 W. MAIN ST.
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524
Mailing Address - Country:US
Mailing Address - Phone:541-826-2525
Mailing Address - Fax:541-826-2876
Practice Address - Street 1:217 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524
Practice Address - Country:US
Practice Address - Phone:541-826-2525
Practice Address - Fax:541-826-2876
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist