Provider Demographics
NPI:1285217877
Name:LUNACEK, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:LUNACEK
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 1:2220 PLYMOUTH AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3047
Mailing Address - Country:US
Mailing Address - Phone:612-543-2500
Mailing Address - Fax:
Practice Address - Street 1:2220 PLYMOUTH AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:612-543-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND146901223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice