Provider Demographics
NPI:1205058245
Name:KELLER, RANDALL S (DDS)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
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 1:250 N ROBERTSON BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1788
Mailing Address - Country:US
Mailing Address - Phone:310-275-4491
Mailing Address - Fax:310-275-4738
Practice Address - Street 1:250 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1788
Practice Address - Country:US
Practice Address - Phone:310-275-4491
Practice Address - Fax:310-275-4738
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38698122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38698OtherDENTAL LICENSE NUMBER