MEDICARE: DR. MICHAEL DAVID KELLER D.M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program	G3-0000382	DE
2	122300000X	Dentist	G1-0001318	DE

General Provider Information

NPI Number	:	1972896322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DAVID KELLER D.M.D.

Provider Business Mailing Address
First Line	:	15254 ROBINSON DR
Second Line	:
City	:	MILTON
State	:	DE
Zip	:	19968-3784
Country	:	US
Telephone Number	:	302-542-6337
Fax Number	:

Provider Business Practice Location Address
First Line	:	19643 BLUE BIRD LN
Second Line	:
City	:	REHOBOTH BEACH
State	:	DE
Zip	:	19971-6129
Country	:	US
Telephone Number	:	302-226-7960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	06/17/2013

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