Basic Information
| Provider Information | |||||||||
| NPI: | 1083685374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEALEY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16 AIRPORT RD | ||||||||
| Address2: | ATTN: KARLEEN MCKENNEY | ||||||||
| City: | WEST LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037841681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032987557 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16 AIRPORT RD | ||||||||
| Address2: | ATTN: KARLEEN MCKENNEY | ||||||||
| City: | WEST LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037841681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032987557 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 22DI01811500 | NJ | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 03876 | NH | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 60194 | CA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.