Provider Demographics
NPI:1093445819
Name:KELLER, MADISON DAWN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:DAWN
Last Name:KELLER
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 WESTPARK DR STE 365
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-5377
Mailing Address - Country:US
Mailing Address - Phone:281-853-8283
Mailing Address - Fax:
Practice Address - Street 1:12360 INTERSTATE 45 NORTH
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378
Practice Address - Country:US
Practice Address - Phone:281-853-8283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX384861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice