Basic Information
| Provider Information | |||||||||
| NPI: | 1871192666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1ST DNBN ATTN: CREDENTIALS | ||||||||
| Address2: | BOX 555221 | ||||||||
| City: | CAMP PENDLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920555221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1ST DNBN ATTN: CREDENTIALS | ||||||||
| Address2: | 555221 BOX | ||||||||
| City: | CAMP PENDLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920555221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2020 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 10583 | NC | Y | Dental Providers | Dental Hygienist |
No ID Information.