Provider Demographics
NPI:1164834628
Name:BUTLER, KEISHA MONIQUE (DDS)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:MONIQUE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 CARLTON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6461
Mailing Address - Country:US
Mailing Address - Phone:504-906-2640
Mailing Address - Fax:
Practice Address - Street 1:85 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4015
Practice Address - Country:US
Practice Address - Phone:718-716-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170123021223G0001X
NY0581351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice