Provider Demographics
NPI:1083876767
Name:IWEN, KYRA A (DDS)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:A
Last Name:IWEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KYRA
Other - Middle Name:A
Other - Last Name:TOULOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:762 MONTANA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3443
Mailing Address - Country:US
Mailing Address - Phone:651-278-7892
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE
Practice Address - Street 2:SCHOOL OF DENTISTRY- DIVISION OF ORTHODONTICS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:651-278-7892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND125191223X0400X
WI6260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist