Basic Information
| Provider Information | |||||||||
| NPI: | 1164834628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | KEISHA | ||||||||
| MiddleName: | MONIQUE | ||||||||
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| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 CARLTON AVE APT 2 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112386461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049062640 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187164400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2017012302 | MO | N | Dental Providers | Dentist | General Practice | 1223G0001X | 058135 | NY | Y | Dental Providers | Dentist | General Practice |
No ID Information.