Provider Demographics
NPI:1073791919
Name:ROSDAHL, KEITH L (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:ROSDAHL
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 COMMERCE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-7419
Mailing Address - Country:US
Mailing Address - Phone:928-771-8166
Mailing Address - Fax:
Practice Address - Street 1:1959 COMMERCE CENTER CIR.
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-771-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-02
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD43451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice