Provider Demographics
NPI:1154780088
Name:KEBER, KRISTINE
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:
Last Name:KEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-3101
Mailing Address - Country:US
Mailing Address - Phone:732-710-0855
Mailing Address - Fax:
Practice Address - Street 1:230 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3101
Practice Address - Country:US
Practice Address - Phone:602-362-0744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-20
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist