Provider Demographics
NPI:1265511844
Name:ROSEBERG, KELLIE ELENA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:ELENA
Last Name:ROSEBERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ELENA
Other - Last Name:MOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 BRIGHTON AVE S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-682-2572
Mailing Address - Fax:763-533-2034
Practice Address - Street 1:306 BRIGHTON AVE S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-682-2572
Practice Address - Fax:763-533-2034
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice