Provider Demographics
NPI:1518614205
Name:KIERSTEN MASELLO DDS PLLC
Entity Type:Organization
Organization Name:KIERSTEN MASELLO DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KIERSTEN
Authorized Official - Middle Name:MICAEL BOEHM
Authorized Official - Last Name:MASELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-587-6846
Mailing Address - Street 1:20438 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5382
Mailing Address - Country:US
Mailing Address - Phone:651-587-6846
Mailing Address - Fax:
Practice Address - Street 1:13832 RIVERWOOD LN
Practice Address - Street 2:
Practice Address - City:CROSSLAKE
Practice Address - State:MN
Practice Address - Zip Code:56442-2823
Practice Address - Country:US
Practice Address - Phone:218-692-4849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental