Provider Demographics
NPI:1205036464
Name:STEPHENSON, KESHA JESELLE
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:JESELLE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18918 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3724
Mailing Address - Country:US
Mailing Address - Phone:301-651-9592
Mailing Address - Fax:
Practice Address - Street 1:12247 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5523
Practice Address - Country:US
Practice Address - Phone:301-933-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10006271223G0001X
MD140591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice