Provider Demographics
NPI:1841347416
Name:KEEFE, JASON C (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:KEEFE
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 1:130 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-8666
Mailing Address - Country:US
Mailing Address - Phone:509-738-6880
Mailing Address - Fax:509-738-6824
Practice Address - Street 1:130 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141-8666
Practice Address - Country:US
Practice Address - Phone:509-738-6880
Practice Address - Fax:509-738-6824
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000066681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5013511Medicaid