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 1:2853 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-1142
Mailing Address - Country:US
Mailing Address - Phone:254-233-2037
Mailing Address - Fax:
Practice Address - Street 1:UNMC COLLEGE OF DENTISTRY 4000 EAST CAMPUS LOOP SOUTH
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68583-0740
Practice Address - Country:US
Practice Address - Phone:402-472-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-12
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34611122300000X, 1223X0400X
NE157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist