Provider Demographics
NPI:1699419150
Name:JANUARY, KEITH EARL JR (MS, DMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:EARL
Last Name:JANUARY
Suffix:JR
Gender:
Credentials:MS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0792
Mailing Address - Country:US
Mailing Address - Phone:318-283-8887
Mailing Address - Fax:318-281-2559
Practice Address - Street 1:314 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3846
Practice Address - Country:US
Practice Address - Phone:318-283-8887
Practice Address - Fax:318-281-6339
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA7359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1873594Medicaid