Provider Demographics
NPI:1215130448
Name:KEEN, C MARK (DDS)
Entity type:Individual
Prefix:
First Name:C
Middle Name:MARK
Last Name:KEEN
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 1:9606 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701
Mailing Address - Country:US
Mailing Address - Phone:909-989-6661
Mailing Address - Fax:909-989-6663
Practice Address - Street 1:9606 BASELINE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701
Practice Address - Country:US
Practice Address - Phone:909-989-6661
Practice Address - Fax:909-989-6663
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA378451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice