Provider Demographics
NPI:1952350738
Name:KELLER, JOHN JAY (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
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 1:3637 WILGUS AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-458-8213
Mailing Address - Fax:920-459-9797
Practice Address - Street 1:3637 WILGUS AVENUE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-458-8213
Practice Address - Fax:920-459-9797
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50019801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33371300Medicaid
WI79744Medicare ID - Type Unspecified
WI33371300Medicaid