Provider Demographics
NPI:1043334311
Name:SELLERS, KEITH T (DDS, MS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:T
Last Name:SELLERS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6406 CARMEL RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8061
Mailing Address - Country:US
Mailing Address - Phone:704-542-9995
Mailing Address - Fax:704-542-9489
Practice Address - Street 1:6406 CARMEL RD
Practice Address - Street 2:SUITE 309
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8061
Practice Address - Country:US
Practice Address - Phone:704-542-9995
Practice Address - Fax:704-542-9489
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics