Provider Demographics
NPI:1356516348
Name:KELLER, PAUL ELLIOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ELLIOTT
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 1:1934 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5907
Mailing Address - Country:US
Mailing Address - Phone:574-533-0722
Mailing Address - Fax:574-534-2333
Practice Address - Street 1:1934 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5907
Practice Address - Country:US
Practice Address - Phone:574-533-0722
Practice Address - Fax:574-534-2333
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007622A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice