Provider Demographics
NPI:1134495591
Name:KELLER, MATTHEW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 N STADIUM DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1884
Mailing Address - Country:US
Mailing Address - Phone:706-225-0444
Mailing Address - Fax:706-940-0008
Practice Address - Street 1:4405 N STADIUM DR STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1884
Practice Address - Country:US
Practice Address - Phone:706-225-0444
Practice Address - Fax:706-940-0008
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0144281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry