Provider Demographics
NPI:1962661223
Name:KELLER, ROGER DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
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 1:1039 HWY 126
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-764-5500
Mailing Address - Fax:423-764-5503
Practice Address - Street 1:1039 HIGHWAY 126
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3223
Practice Address - Country:US
Practice Address - Phone:423-764-5500
Practice Address - Fax:423-764-5503
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist