Provider Demographics
NPI:1730452236
Name:MCCUNE, KESHIA NICHELLE (BS RDH)
Entity type:Individual
Prefix:MRS
First Name:KESHIA
Middle Name:NICHELLE
Last Name:MCCUNE
Suffix:
Gender:F
Credentials:BS RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 414
Mailing Address - Street 2:BOX 2267
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 KELLEY ST.
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:92655
Practice Address - Country:US
Practice Address - Phone:314-475-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH010815124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist