Provider Demographics
NPI:1275688020
Name:KOLLER, MICHAEL D (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:KOLLER
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42256-0040
Mailing Address - Country:US
Mailing Address - Phone:270-755-4899
Mailing Address - Fax:270-755-3285
Practice Address - Street 1:288 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:KY
Practice Address - Zip Code:42256
Practice Address - Country:US
Practice Address - Phone:270-755-4899
Practice Address - Fax:270-755-3285
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60062304Medicaid