Provider Demographics
NPI:1285639815
Name:KOEHNEN, KELLY K (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:KOEHNEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W LAKE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2653
Mailing Address - Country:US
Mailing Address - Phone:612-827-3736
Mailing Address - Fax:612-821-9626
Practice Address - Street 1:1406 W LAKE ST
Practice Address - Street 2:STE 100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2653
Practice Address - Country:US
Practice Address - Phone:612-827-3736
Practice Address - Fax:612-821-9626
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN109851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice