Provider Demographics
NPI:1902895642
Name:KOLLER, JAMES GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
Last Name:KOLLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 CENTENNIAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3087
Mailing Address - Country:US
Mailing Address - Phone:651-777-6454
Mailing Address - Fax:651-773-9206
Practice Address - Street 1:2534 7TH AVE E
Practice Address - Street 2:
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3003
Practice Address - Country:US
Practice Address - Phone:651-777-6454
Practice Address - Fax:651-773-9206
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-16
Last Update Date:2019-11-18
Deactivation Date:2019-10-31
Deactivation Code:
Reactivation Date:2019-11-18
Provider Licenses
StateLicense IDTaxonomies
MN103661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice