Provider Demographics
NPI:1073121166
Name:POWELL, KIRA JEANNETTE (DDS)
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:JEANNETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-0308
Mailing Address - Country:US
Mailing Address - Phone:763-263-7100
Mailing Address - Fax:763-263-7100
Practice Address - Street 1:20460 COUNTY ROAD 11 NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4851
Practice Address - Country:US
Practice Address - Phone:763-263-7100
Practice Address - Fax:763-263-7114
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice