Provider Demographics
NPI:1407027402
Name:CARLA M. KEENE, D.D.S.
Entity Type:Organization
Organization Name:CARLA M. KEENE, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KEENE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-676-0070
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-0287
Mailing Address - Country:US
Mailing Address - Phone:276-676-0070
Mailing Address - Fax:276-676-0880
Practice Address - Street 1:15189 PORTERFIELD HIGHWAY
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211
Practice Address - Country:US
Practice Address - Phone:276-676-0070
Practice Address - Fax:276-676-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010075891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1461995OtherUNITED CONCORDIA
VA178416OtherANTHEM
VA9178537Medicaid