Provider Demographics
NPI:1770040974
Name:KEATHLEY, COREY MICHELE (RHDAP)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MICHELE
Last Name:KEATHLEY
Suffix:
Gender:F
Credentials:RHDAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NANTES WAY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-1539
Mailing Address - Country:US
Mailing Address - Phone:661-706-8221
Mailing Address - Fax:
Practice Address - Street 1:2200 NANTES WAY
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-1539
Practice Address - Country:US
Practice Address - Phone:661-707-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist