Provider Demographics
NPI:1376603308
Name:WASHINGTON, KEYSRA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEYSRA
Middle Name:MARIE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KEYSRA
Other - Middle Name:MARIE
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2944 NADAR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6728
Mailing Address - Country:US
Mailing Address - Phone:615-293-4136
Mailing Address - Fax:
Practice Address - Street 1:1336 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-7417
Practice Address - Country:US
Practice Address - Phone:972-329-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA852802311CMedicaid