1578912341 NPI number — DR. JOHNATHAN MICHAEL KELLER DDS

Table of content: DR. JOHNATHAN MICHAEL KELLER DDS (NPI 1578912341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578912341 NPI number — DR. JOHNATHAN MICHAEL KELLER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
JOHNATHAN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578912341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3715 KENTUCKY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46221-2757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-946-4464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 W MICHIGAN ST
Provider Second Line Business Practice Location Address:
FH204
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-0076
Provider Business Practice Location Address Fax Number:
317-274-0256
Provider Enumeration Date:
06/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12012526A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1578912341 . This is a "NPI TYPE 1" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 13885169 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 12012526A . This is a "IN DENTAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201375420 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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