Provider Demographics
NPI:1316362619
Name:OULIE, KEITH (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:OULIE
Suffix:
Gender:M
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:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23040-0051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 BROWN RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:VA
Practice Address - Zip Code:23040-2119
Practice Address - Country:US
Practice Address - Phone:804-492-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-23
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401004351OtherVIRGINIA DENTAL LICENSE