Provider Demographics
NPI:1174511570
Name:KJELLBERG, GREGORY BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BRUCE
Last Name:KJELLBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 JONATHAN DR
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:MN
Mailing Address - Zip Code:56073-3343
Mailing Address - Country:US
Mailing Address - Phone:507-354-4225
Mailing Address - Fax:
Practice Address - Street 1:127 N BROADWAY ST
Practice Address - Street 2:PO 848
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-1715
Practice Address - Country:US
Practice Address - Phone:507-233-9400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice