Provider Demographics
NPI:1649360850
Name:KELLER, TREVOR HOWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:HOWARD
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 1:159 JEFFERSON HTS
Mailing Address - Street 2:SUITE A-202
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-1237
Mailing Address - Country:US
Mailing Address - Phone:518-943-0780
Mailing Address - Fax:518-943-0783
Practice Address - Street 1:159 JEFFERSON HTS
Practice Address - Street 2:SUITE A-202
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1237
Practice Address - Country:US
Practice Address - Phone:518-943-0780
Practice Address - Fax:518-943-0783
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0486181223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02208542Medicaid
NY10072049OtherCDPHP