Provider Demographics
NPI:1942228176
Name:KELLER, KLINT R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KLINT
Middle Name:R
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 1:203 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3846
Mailing Address - Country:US
Mailing Address - Phone:208-466-8400
Mailing Address - Fax:208-466-8436
Practice Address - Street 1:203 7TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3846
Practice Address - Country:US
Practice Address - Phone:208-466-8400
Practice Address - Fax:208-466-8436
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID01478887OtherUNITED CONCORDIA INS
ID806628200Medicaid
ID000010143908OtherBLUE SHIELD OF ID
ID6H361OtherBLUE CROSS INS