Provider Demographics
NPI:1538388715
Name:KELLER, GARY DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DALE
Last Name:KELLER
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 1:1005 N PINES RD
Mailing Address - Street 2:SUITE #300
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4986
Mailing Address - Country:US
Mailing Address - Phone:509-926-1161
Mailing Address - Fax:509-926-2106
Practice Address - Street 1:1005 N PINES RD
Practice Address - Street 2:SUITE #300
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4986
Practice Address - Country:US
Practice Address - Phone:509-926-1161
Practice Address - Fax:509-926-2106
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist