1407835002 NPI number — DR. KEISHA PATRICE BRUNEY JUDD DMD

Table of content: DR. KEISHA PATRICE BRUNEY JUDD DMD (NPI 1407835002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407835002 NPI number — DR. KEISHA PATRICE BRUNEY JUDD DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUDD
Provider First Name:
KEISHA
Provider Middle Name:
PATRICE BRUNEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUNEY
Provider Other First Name:
KEISHA
Provider Other Middle Name:
PATRICE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407835002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7015 FITZPATRICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20707-3208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-812-3930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8363 CHERRY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20707-4831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-812-3930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13389 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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