Provider Demographics
NPI:1184634552
Name:KELLER, TRACIE EILEEN (DDS)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:EILEEN
Last Name:KELLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6760 CORPORATE DRIVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919
Mailing Address - Country:US
Mailing Address - Phone:719-528-8822
Mailing Address - Fax:719-593-9855
Practice Address - Street 1:6760 CORPORATE DRIVE
Practice Address - Street 2:SUITE 270
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919
Practice Address - Country:US
Practice Address - Phone:719-528-8822
Practice Address - Fax:719-593-9855
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist