Provider Demographics
NPI:1609303486
Name:KELLER, KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
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 1:111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1433
Mailing Address - Country:US
Mailing Address - Phone:330-336-5788
Mailing Address - Fax:330-334-1425
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1433
Practice Address - Country:US
Practice Address - Phone:330-336-5788
Practice Address - Fax:330-334-1425
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist