Provider Demographics
NPI:1588714141
Name:KELLER, JOHN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
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 1:552 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:763-421-4550
Mailing Address - Fax:763-421-5428
Practice Address - Street 1:552 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-421-4550
Practice Address - Fax:763-421-5428
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10034OtherDENTAL