Provider Demographics
NPI:1538207493
Name:KELLER, DARREL D (DMD)
Entity type:Individual
Prefix:DR
First Name:DARREL
Middle Name:D
Last Name:KELLER
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 1:282 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-1833
Mailing Address - Country:US
Mailing Address - Phone:618-327-4422
Mailing Address - Fax:618-327-4423
Practice Address - Street 1:282 S MILL ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1833
Practice Address - Country:US
Practice Address - Phone:618-327-4422
Practice Address - Fax:618-327-4423
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-A160161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice