Provider Demographics
NPI:1669564613
Name:KELLER, JONATHAN ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ANDREW
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 1:21300 N. JOHN WAYNE PARKWAY
Mailing Address - Street 2:SUITE #118
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85239
Mailing Address - Country:US
Mailing Address - Phone:520-568-8470
Mailing Address - Fax:520-568-9510
Practice Address - Street 1:21300 N. JOHN WAYNE PARKWAY
Practice Address - Street 2:SUITE #118
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85239
Practice Address - Country:US
Practice Address - Phone:520-568-8470
Practice Address - Fax:520-568-9510
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist