Provider Demographics
NPI:1942546072
Name:KEITHLY, INGA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:MARIE
Last Name:KEITHLY
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 1:315 MCHUGH BLVD, 2D DENBN/NDC
Mailing Address - Street 2:PSC BOX 20130 COMMANDING OFFICER
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0130
Mailing Address - Country:US
Mailing Address - Phone:910-451-2208
Mailing Address - Fax:910-451-8036
Practice Address - Street 1:315 MCHUGH BLVD, 2D DENBN/NDC
Practice Address - Street 2:PSC BOX 20130 COMMANDING OFFICER
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0130
Practice Address - Country:US
Practice Address - Phone:910-451-2208
Practice Address - Fax:910-451-8036
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8447979-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist