Provider Demographics
NPI:1558711655
Name:CASTELLUCCI, KEREN ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:KEREN
Middle Name:ELIZABETH
Last Name:CASTELLUCCI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4906
Mailing Address - Country:US
Mailing Address - Phone:407-383-6738
Mailing Address - Fax:
Practice Address - Street 1:621 SEBASTIAN BLVD STE C
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-4345
Practice Address - Country:US
Practice Address - Phone:352-483-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL211121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry