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General NPI Number Information
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NPI Number | 1356990097
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Entity Type | Individual
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Provider Name | MATTHEW KELLER
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Gender | Male
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Dates
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Enumeration Date | 09/05/2019
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Last Update Date | 09/05/2019
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Provider Practice Location Address
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Address Line | 8951 BONITA BEACH RD SE STE 220
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-4202
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Country | US
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Telephone | 239-674-3069
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Fax |
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Provider Business Mailing Address
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Address Line | 413 S WAY CT
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City | SALEM
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State | SC
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Zip | 29676-4625
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Country | US
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Telephone |
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DN24536
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License Number State | FL
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