Provider Demographics
NPI:1497468391
Name:BRIAN J KELLER DDS & TRACIE E KELLER DDS PROF LLP
Entity Type:Organization
Organization Name:BRIAN J KELLER DDS & TRACIE E KELLER DDS PROF LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-528-8822
Mailing Address - Street 1:6760 CORPORATE DRIVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919
Mailing Address - Country:US
Mailing Address - Phone:719-528-8822
Mailing Address - Fax:719-593-9855
Practice Address - Street 1:6760 CORPORATE DRIVE
Practice Address - Street 2:SUITE 270
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919
Practice Address - Country:US
Practice Address - Phone:719-528-8822
Practice Address - Fax:719-593-9855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty