Provider Demographics
NPI:1730650037
Name:KELLER, KRISTOPHER JACOB (DDS)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:JACOB
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 1:1200 PULITZER PL
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1568
Mailing Address - Country:US
Mailing Address - Phone:423-246-3001
Mailing Address - Fax:
Practice Address - Street 1:1200 PULITZER PL
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1568
Practice Address - Country:US
Practice Address - Phone:423-246-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-12
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN129481223X0400X
NE157122300000X
TX346111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist