Ketti R Boller, D.D.S, M.S

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

12014618A Issued in IN

Practice address

123 N Main St Ste 101
Crown Point, IN 46307-4077

Phone

(219) 663-2000

Fax

(219) 322-7667

NPI assigned

Sep 25, 2012

Last updated

Apr 17, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Science

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• The Board of Trustees of the University of Illinois

  • Anatomic Pathology Physician
  • Chicago, IL
  • NPI 1386863819
  Medicare reassignment NPD
• The Board of Trustees of the University of Illinois

  dba Occupational Health Service Institute (OHSI)

  • Occupational Medicine Physician
  • Chicago, IL
  • NPI 1043727571
  NPD
• The Board of Trustees of the University of Illinois

  • Surgery Physician
  • Chicago, IL
  • NPI 1265651392
  NPD
• Ellis Orthodontics, LLC

  • Orthodontics and Dentofacial Orthopedics Dentistry
  • Dyer, IN
  • NPI 1700070331
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1348531200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1744848000000",
    "number": "1255682662",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "123 N MAIN ST STE 101",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463074077",
            "telephone_number": "219-663-2000",
            "fax_number": "219-322-7667"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "123 N MAIN ST STE 101",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463074077",
            "telephone_number": "219-663-2000",
            "fax_number": "219-322-7667"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "275 Joliet St Ste 260",
            "address_purpose": "LOCATION",
            "city": "Dyer",
            "state": "IN",
            "postal_code": "463111798",
            "country_code": "US",
            "telephone_number": "219-322-7645",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOLLER",
        "first_name": "KETTI",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "D.D.S, M.S",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2012-09-25",
        "last_updated": "2025-04-17",
        "certification_date": "2025-04-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "IN",
            "license": "12014618A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peter Luke Bochniak II, FNP-BC
• Mariya Bodnar, DMD
• Sheila Kay Bogart, OD
• Michael Jason Bohney, PA-C
• Tabitha Bolden, MS.
• Bret A Bologna, DDS
• Michelle R Bonadies, LCSW
• Artricia Desiree Bonaparte
• Suzanne Jean Bonaventura-Krischke, MSW
• Neeru Bose, M.D

• Orthodontics and Dentofacial Orthopedics Dentistry in Crown Point, IN
• Providers in Crown Point, IN by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.