Healthcare Provider Details

I. General information

NPI: 1861325011
Provider Name (Legal Business Name): PAYTON KELLER JUDY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 N PARK AVE
SHAWNEE OK
74804-2838
US

IV. Provider business mailing address

2616 N PARK AVE
SHAWNEE OK
74804-2838
US

V. Phone/Fax

Practice location:
  • Phone: 405-275-7730
  • Fax:
Mailing address:
  • Phone: 405-275-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8232
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: