Healthcare Provider Details

I. General information

NPI: 1508918137
Provider Name (Legal Business Name): MARY S KEITER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6441 IRONBRIDGE ROAD
RICHMOND VA
23234
US

IV. Provider business mailing address

1612 HUGUENOT ROAD
MIDLOTHIAN VA
23113
US

V. Phone/Fax

Practice location:
  • Phone: 804-743-8166
  • Fax: 804-743-4818
Mailing address:
  • Phone: 804-794-9789
  • Fax: 804-794-9762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401007816
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: