Provider Demographics
NPI:1912281965
Name:KELLER, JOHN B (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
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 1:1701 CLEARWATER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6433
Mailing Address - Country:US
Mailing Address - Phone:309-662-7949
Mailing Address - Fax:309-664-6177
Practice Address - Street 1:1701 CLEARWATER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6433
Practice Address - Country:US
Practice Address - Phone:309-662-7949
Practice Address - Fax:309-664-6177
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190228291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice