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General NPI Number Information
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NPI Number | 1255682662
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Entity Type | Individual
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Provider Name | KETTI R BOLLER D.D.S, M.S
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Gender | Female
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Dates
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Enumeration Date | 09/25/2012
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 123 N MAIN ST STE 101
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City | CROWN POINT
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State | IN
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Zip | 46307-4077
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Country | US
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Telephone | 219-663-2000
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Fax | 219-322-7667
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Provider Business Mailing Address
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Address Line | 123 N MAIN ST STE 101
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City | CROWN POINT
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State | IN
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Zip | 46307-4077
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Country | US
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Telephone | 219-663-2000
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Fax | 219-322-7667
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12014618A
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License Number State | IN
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