MEDICARE: DR. KEISHA R BROWN D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7478	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7478	OTHER	NC	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1376621714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEISHA R BROWN D.D.S

Provider Business Mailing Address
First Line	:	6213 ROCK QUARRY RD
Second Line	:	110
City	:	RALEIGH
State	:	NC
Zip	:	27610-6640
Country	:	US
Telephone Number	:	919-661-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6213 ROCK QUARRY RD
Second Line	:	110
City	:	RALEIGH
State	:	NC
Zip	:	27610-6640
Country	:	US
Telephone Number	:	919-661-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	09/07/2011

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