Provider Demographics
NPI:1992955249
Name:KEITH W. STREET DMD LLC
Entity type:Organization
Organization Name:KEITH W. STREET DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-224-2526
Mailing Address - Street 1:110 BUFORD AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3314
Mailing Address - Country:US
Mailing Address - Phone:864-224-2526
Mailing Address - Fax:
Practice Address - Street 1:110 BUFORD AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3314
Practice Address - Country:US
Practice Address - Phone:864-224-2526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2894 SPEC 03911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty