Provider Demographics
NPI:1114150059
Name:KELLER, SARAH VIRGINIA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:VIRGINIA
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:VIRGINIA
Other - Last Name:VERBANAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5701 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:5701 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112
Practice Address - Country:US
Practice Address - Phone:314-367-7848
Practice Address - Fax:314-367-2985
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009022782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO105450014Medicare PIN