Provider Demographics
NPI:1912120676
Name:KELLER, G. WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:G.
Middle Name:WILLIAM
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 1:1110 N BANCROFT PKWY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2669
Mailing Address - Country:US
Mailing Address - Phone:302-652-3586
Mailing Address - Fax:302-652-1174
Practice Address - Street 1:1110 N BANCROFT PKWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2669
Practice Address - Country:US
Practice Address - Phone:302-652-3586
Practice Address - Fax:302-652-1174
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00008991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE42446Medicare UPIN
DE191870Medicare ID - Type Unspecified