Provider Demographics
NPI:1356475636
Name:DR. DOUGLAS A. KELLER,D.M.D., P.C.
Entity Type:Organization
Organization Name:DR. DOUGLAS A. KELLER,D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-669-0027
Mailing Address - Street 1:420 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3008
Mailing Address - Country:US
Mailing Address - Phone:631-669-0027
Mailing Address - Fax:631-669-0054
Practice Address - Street 1:420 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3008
Practice Address - Country:US
Practice Address - Phone:631-669-0027
Practice Address - Fax:631-669-0054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0356641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty