Provider Demographics
NPI:1760562334
Name:KELLER, JOHN DAVID IV (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:KELLER
Suffix:IV
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 1:4920 HONONEGAH RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7778
Mailing Address - Country:US
Mailing Address - Phone:815-623-3926
Mailing Address - Fax:815-623-3930
Practice Address - Street 1:4920 HONONEGAH RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7778
Practice Address - Country:US
Practice Address - Phone:815-623-3926
Practice Address - Fax:815-623-3930
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice