Provider Demographics
NPI:1578912341
Name:KELLER, JOHNATHAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:MICHAEL
Last Name:KELLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-2757
Mailing Address - Country:US
Mailing Address - Phone:317-946-4464
Mailing Address - Fax:
Practice Address - Street 1:1130 W MICHIGAN ST
Practice Address - Street 2:FH204
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-274-0076
Practice Address - Fax:317-274-0256
Is Sole Proprietor?:No
Enumeration Date:2016-06-12
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012526A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1578912341OtherNPI TYPE 1
IN13885169OtherCAQH
IN12012526AOtherIN DENTAL LICENSE
IN201375420Medicaid