Basic Information
| Provider Information | |||||||||
| NPI: | 1942546072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITHLY | ||||||||
| FirstName: | INGA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 315 MCHUGH BLVD, 2D DENBN/NDC | ||||||||
| Address2: | PSC BOX 20130 COMMANDING OFFICER | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MCHUGH BLVD, 2D DENBN/NDC | ||||||||
| Address2: | PSC BOX 20130 COMMANDING OFFICER | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8447979-9921 | UT | Y | Dental Providers | Dentist |
No ID Information.