Provider Demographics
NPI:1548642374
Name:KEEN, KAITLYN BURGESS (DMD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:BURGESS
Last Name:KEEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:MICHELLE
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1045 E STEWART AVE BLDG 2012T
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80914-2900
Mailing Address - Country:US
Mailing Address - Phone:719-556-1333
Mailing Address - Fax:
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-269-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21499122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist