Basic Information
| Provider Information | |||||||||
| NPI: | 1114150059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | VIRGINIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VERBANAZ | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | VIRGINIA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5701 DELMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143677848 | ||||||||
| FaxNumber: | 3143672985 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 DELMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143677848 | ||||||||
| FaxNumber: | 3143672985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2009022782 | MO | Y | Dental Providers | Dentist |
No ID Information.