Provider Demographics
NPI:1972896322
Name:KELLER, MICHAEL DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:KELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15254 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-3784
Mailing Address - Country:US
Mailing Address - Phone:302-542-6337
Mailing Address - Fax:
Practice Address - Street 1:19643 BLUE BIRD LN
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6129
Practice Address - Country:US
Practice Address - Phone:302-226-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG3-0000382390200000X
DEG1-0001318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program