Provider Demographics
NPI:1538118526
Name:KRELLER, J SKELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:SKELLY
Last Name:KRELLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 C M FAGAN DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-6055
Mailing Address - Country:US
Mailing Address - Phone:985-542-9608
Mailing Address - Fax:985-542-3114
Practice Address - Street 1:1000 C M FAGAN DR
Practice Address - Street 2:SUITE C
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-6055
Practice Address - Country:US
Practice Address - Phone:985-542-9608
Practice Address - Fax:985-542-3114
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1826511Medicaid
LAT19838Medicare UPIN
LA1826511Medicaid