Provider Demographics
NPI:1154614758
Name:DUONGVANNAK KEO, DMD
Entity type:Organization
Organization Name:DUONGVANNAK KEO, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DUONGVANNAK
Authorized Official - Middle Name:JB
Authorized Official - Last Name:KEO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD CAGS
Authorized Official - Phone:321-452-6000
Mailing Address - Street 1:295 S. PLUMOSA
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-452-6000
Mailing Address - Fax:321-453-8823
Practice Address - Street 1:295 S. PLUMOSA
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-452-6000
Practice Address - Fax:321-453-8823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 13955122300000X
FLDN 19124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty