Provider Demographics
NPI:1588858260
Name:KELLER, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
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 1:1310 E DIMOND BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2031
Mailing Address - Country:US
Mailing Address - Phone:907-336-7337
Mailing Address - Fax:
Practice Address - Street 1:1310 E DIMOND BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2031
Practice Address - Country:US
Practice Address - Phone:907-336-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND116901223P0221X
AK1511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry