Provider Demographics
NPI:1518032432
Name:QUINN, KEISHA DENYEL (DDS)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:DENYEL
Last Name:QUINN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 NORTH COOK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440
Mailing Address - Country:US
Mailing Address - Phone:601-649-4854
Mailing Address - Fax:601-649-4828
Practice Address - Street 1:304 NORTH COOK AVENUE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-649-4854
Practice Address - Fax:601-649-4828
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2569901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060078Medicaid