Provider Demographics
NPI:1659625143
Name:KEEFER, KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KEEFER
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 1:8404 DORSEY CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4592
Mailing Address - Country:US
Mailing Address - Phone:703-330-5755
Mailing Address - Fax:
Practice Address - Street 1:8404 DORSEY CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4592
Practice Address - Country:US
Practice Address - Phone:703-330-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413738122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist