Healthcare Provider Details

I. General information

NPI: 1801866793
Provider Name (Legal Business Name): KEITRA TUNISHA GEORGE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

IV. Provider business mailing address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7925
  • Fax: 757-314-7926
Mailing address:
  • Phone: 757-314-7925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036217
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS036217
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: