Provider Demographics
NPI:1083628515
Name:KETTLER, SHARON K (RDH)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:K
Last Name:KETTLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 SIOUX TRL NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9077
Mailing Address - Country:US
Mailing Address - Phone:952-496-6148
Mailing Address - Fax:952-233-4224
Practice Address - Street 1:2330 SIOUX TRL NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-9077
Practice Address - Country:US
Practice Address - Phone:952-496-6148
Practice Address - Fax:952-233-4224
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5650124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist