MEDICARE: CHARLES A KELLER DDS AND ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8352	MN

General Provider Information

NPI Number	:	1598935256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES A KELLER DDS AND ASSOCIATES

Provider Business Mailing Address
First Line	:	919 MARYLAND AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55106-2618
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	919 MARYLAND AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55106-2618
Country	:	US
Telephone Number	:	651-776-8355
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES A KELLER
Credential	:	DDS
Telephone Number	:	651-776-8355

Provider Enumeration Date	:	03/08/2008
Last Update Date	:	03/08/2008

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