# JOHNATHON KELLER DDS LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Decatur Woods Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790300242
- **Authorized official:** JOHNATHON M KELLER DDS (DENTIST)
- **Authorized official phone:** (317) 946-4464

## Contact information

- **Practice address:** 3715 KENTUCKY AVE, INDIANAPOLIS, IN 46221-2757
- **Practice address phone:** (317) 946-4464
- **Mailing address:** 3715 KENTUCKY AVE, INDIANAPOLIS, IN 46221-2757
- **Mailing address phone:** (317) 946-4464

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 06/10/2020
- **Last updated:** 06/10/2020

## 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 |