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General NPI Number Information
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NPI Number | 1366460107
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Entity Type | Organization
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Legal Business Name | KEETON, GOKLI, LUBBE, BRIDGES-POQUIS & RADDIN,
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Dates
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Enumeration Date | 07/18/2006
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Last Update Date | 02/11/2011
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Provider Practice Location Address
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Address Line | 13841 HULL STREET RD SUITE 4
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City | MIDLOTHIAN
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State | VA
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Zip | 23112-2056
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Country | US
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Telephone | 804-739-0963
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Fax | 804-739-0965
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Provider Business Mailing Address
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Address Line | 13841 HULL STREET RD SUITE 4
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City | MIDLOTHIAN
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State | VA
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Zip | 23112-2056
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Country | US
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Telephone | 804-739-0963
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Fax | 804-739-0965
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MS. CAROL ROPER
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Credential |
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Telephone | 804-739-0963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401410240
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401007234
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0401410225
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License Number State | VA
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Taxonomy #4
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0401004475
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License Number State | VA
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Taxonomy #5
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401004876
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License Number State | VA
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