MEDICARE: JUNE KELLER VERNON 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	1223G0001X	General Practice Dentistry	VA7324	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	615937	OTHER	VA	UNITED CONCORDIA
2	070781	OTHER	VA	ANTHEM BCBS

General Provider Information

NPI Number	:	1861485393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUNE KELLER VERNON D.D.S.

Provider Business Mailing Address
First Line	:	241 CHARLES H DIMMOCK PKWY
Second Line	:	SUITE 2
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2915
Country	:	US
Telephone Number	:	804-520-0699
Fax Number	:	804-520-1765

Provider Business Practice Location Address
First Line	:	241 CHARLES H DIMMOCK PKWY
Second Line	:	SUITE 2
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2915
Country	:	US
Telephone Number	:	804-520-0699
Fax Number	:	804-520-1765

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	08/10/2007

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Directions to “ JUNE KELLER VERNON D.D.S.” Practice Location

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