Provider Demographics
NPI:1679887509
Name:BRACKEN, MONLEUDY KEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONLEUDY
Middle Name:KEO
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25229 TAYLOR ST APT D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3032
Mailing Address - Country:US
Mailing Address - Phone:916-233-5951
Mailing Address - Fax:
Practice Address - Street 1:4072 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2820
Practice Address - Country:US
Practice Address - Phone:757-405-6293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice