Provider Demographics
NPI:1306494497
Name:KELLER, KATELYN (DDS)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19767 COCONUT HARBOR CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5078
Mailing Address - Country:US
Mailing Address - Phone:814-934-5390
Mailing Address - Fax:
Practice Address - Street 1:5037 S CLEVELAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1377
Practice Address - Country:US
Practice Address - Phone:239-236-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0424531223G0001X
FLDN243891223G0001X
FL243891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice