Provider Demographics
NPI:1902971708
Name:DECKER, KEENAN R (DMD)
Entity type:Individual
Prefix:DR
First Name:KEENAN
Middle Name:R
Last Name:DECKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 SOUTHERN HILLS BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8013
Mailing Address - Country:US
Mailing Address - Phone:479-659-0900
Mailing Address - Fax:479-659-0902
Practice Address - Street 1:3608 SOUTHERN HILLS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8013
Practice Address - Country:US
Practice Address - Phone:479-659-0900
Practice Address - Fax:479-659-0902
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice