Healthcare Provider Details

I. General information

NPI: 1962572321
Provider Name (Legal Business Name): DAVID LARSEN KELLER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11415 SW SCHOLLS FERRY RD
BEAVERTON OR
97008-7168
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 503-524-7493
  • Fax: 503-524-1077
Mailing address:
  • Phone: 503-952-2164
  • Fax: 503-526-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD4529
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: