Provider Demographics
NPI:1851410583
Name:KELLER, STEPHANIE MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52248 SE ENDICOTT LN
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-3311
Mailing Address - Country:US
Mailing Address - Phone:503-543-3777
Mailing Address - Fax:
Practice Address - Street 1:17675 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4443
Practice Address - Country:US
Practice Address - Phone:503-259-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113652126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant