Individual
DR. JOHNATHAN MICHAEL KELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1130 W MICHIGAN ST, FH204, INDIANAPOLIS, IN 46202-5209
(317) 274-0076
(317) 274-0256
Mailing address
3715 KENTUCKY AVE, INDIANAPOLIS, IN 46221-2757
(317) 946-4464
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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