Provider Demographics
NPI:1235253303
Name:KELLER, MICHAEL EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
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 1:38 MERCURY CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2413
Mailing Address - Country:US
Mailing Address - Phone:732-525-0049
Mailing Address - Fax:732-525-0089
Practice Address - Street 1:236 ERNSTON RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1926
Practice Address - Country:US
Practice Address - Phone:732-525-0049
Practice Address - Fax:732-525-0089
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023195031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice