Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 9671 | MN |
NPI | 1891786224 |
---|---|
Provider Name | Dr. Thomas Maurice Keane JR. |
First Address | Bloomington, MN 55431 |
Second Address | Bloomington, MN 55431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 24/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
776322100 | (05) | MN |