Provider Demographics
NPI:1164800322
Name:KEMMER, MARIAH ROSE
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ROSE
Last Name:KEMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19033 US 71
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-3202
Mailing Address - Country:US
Mailing Address - Phone:218-732-3291
Mailing Address - Fax:
Practice Address - Street 1:19033 US 71
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-3202
Practice Address - Country:US
Practice Address - Phone:218-732-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH9565124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist