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Individual
DR. JOHNATHAN MICHAEL KELLER
Active
Individual
DR. JOHNATHAN MICHAEL KELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12012526A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12012526A
IN DENTAL LICENSE
IN
01
—
13885169
CAQH
IN
01
—
1578912341
NPI TYPE 1
IN
05
—
201375420
—
IN
Enumeration date
06/12/2016
Last updated
06/10/2020
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