Provider Demographics
NPI:1104024264
Name:KEBRIAEI, AMY JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JEAN
Last Name:KEBRIAEI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JEAN
Other - Last Name:HAWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17510 DODD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044
Mailing Address - Country:US
Mailing Address - Phone:952-997-7100
Mailing Address - Fax:952-997-2017
Practice Address - Street 1:17510 DODD BLVD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-997-7100
Practice Address - Fax:952-997-2017
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE67091223P0221X
MND127291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry