Provider Demographics
NPI:1366460107
Name:KEETON, GOKLI, LUBBE, BRIDGES-POQUIS & RADDIN,
Entity Type:Organization
Organization Name:KEETON, GOKLI, LUBBE, BRIDGES-POQUIS & RADDIN,
Other - Org Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-739-0963
Mailing Address - Street 1:13841 HULL STREET RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2056
Mailing Address - Country:US
Mailing Address - Phone:804-739-0963
Mailing Address - Fax:804-739-0965
Practice Address - Street 1:13841 HULL STREET RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2056
Practice Address - Country:US
Practice Address - Phone:804-739-0963
Practice Address - Fax:804-739-0965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102401223P0221X
VA04010072341223P0221X
VA04010048761223P0221X
VA04014102251223X0400X
VA04010044751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty