Basic Information
| Provider Information | |||||||||
| NPI: | 1578912341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3715 KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462212757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179464464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1130 W MICHIGAN ST | ||||||||
| Address2: | FH204 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172740076 | ||||||||
| FaxNumber: | 3172740256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2016 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 12012526A | IN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1578912341 | 01 | IN | NPI TYPE 1 | OTHER | 13885169 | 01 | IN | CAQH | OTHER | 12012526A | 01 | IN | IN DENTAL LICENSE | OTHER | 201375420 | 05 | IN | MEDICAID |