Provider Demographics
NPI:1790839959
Name:KELLER, DAVID
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MAYOR MCGRATH HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MD
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-472-1036
Mailing Address - Fax:
Practice Address - Street 1:66 MAYOR MCGRATH HIGHWAY
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MD
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-472-1036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist