Provider Demographics
NPI:1255682662
Name:BOLLER, KETTI R (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KETTI
Middle Name:R
Last Name:BOLLER
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9535 W 144TH PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2556
Mailing Address - Country:US
Mailing Address - Phone:708-403-2288
Mailing Address - Fax:
Practice Address - Street 1:9535 W 144TH PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2556
Practice Address - Country:US
Practice Address - Phone:708-403-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0024831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics