Provider Demographics
NPI:1255682662
Name:BOLLER, KETTI R (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:KETTI
Middle Name:R
Last Name:BOLLER
Suffix:
Gender:
Credentials:DDS, MS
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Mailing Address - Street 1:123 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4077
Mailing Address - Country:US
Mailing Address - Phone:219-663-2000
Mailing Address - Fax:219-322-7667
Practice Address - Street 1:123 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4077
Practice Address - Country:US
Practice Address - Phone:219-663-2000
Practice Address - Fax:219-322-7667
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014618A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics