Provider Demographics
NPI:1215272646
Name:PAMELA J. KELLER, DMD, P.A.
Entity type:Organization
Organization Name:PAMELA J. KELLER, DMD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-631-6808
Mailing Address - Street 1:301 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-2333
Mailing Address - Country:US
Mailing Address - Phone:386-698-1138
Mailing Address - Fax:386-698-1183
Practice Address - Street 1:301 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2333
Practice Address - Country:US
Practice Address - Phone:386-698-1138
Practice Address - Fax:386-698-1183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 107731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty