Provider Demographics
NPI:1962419317
Name:KELLERMAN, KEVIN JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:KELLERMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JUNCTION DR W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2996
Mailing Address - Country:US
Mailing Address - Phone:618-228-3100
Mailing Address - Fax:618-288-3434
Practice Address - Street 1:16 JUNCTION DR W
Practice Address - Street 2:SUITE 101
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2996
Practice Address - Country:US
Practice Address - Phone:618-228-3100
Practice Address - Fax:618-288-3434
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0258621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL108441Medicaid