Provider Demographics
NPI:1528557824
Name:MONLEUDY KEO BRACKEN, DDS, PLLC
Entity Type:Organization
Organization Name:MONLEUDY KEO BRACKEN, DDS, PLLC
Other - Org Name:VIBRANT SMILE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-466-1700
Mailing Address - Street 1:5715 SELLGER DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-5239
Mailing Address - Country:US
Mailing Address - Phone:757-466-1700
Mailing Address - Fax:757-416-6850
Practice Address - Street 1:5715 SELLGER DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-5239
Practice Address - Country:US
Practice Address - Phone:757-466-1700
Practice Address - Fax:757-416-6850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty