Provider Demographics
NPI:1376750588
Name:KELLER, SUZANNE RENEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-3100
Mailing Address - Country:US
Mailing Address - Phone:413-586-9363
Mailing Address - Fax:413-387-6500
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-3100
Practice Address - Country:US
Practice Address - Phone:413-586-9363
Practice Address - Fax:413-387-6500
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice