Provider Demographics
NPI:1497311245
Name:DELVEAUX, KALLIE (DDS)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:DELVEAUX
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 1:2900 UNIVERSITY AVE SE APT 203
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3733
Mailing Address - Country:US
Mailing Address - Phone:309-706-2829
Mailing Address - Fax:
Practice Address - Street 1:1632 WASHINGTON ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1336
Practice Address - Country:US
Practice Address - Phone:612-789-2853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice