Provider Demographics
NPI:1588622799
Name:VENTRUCCI, KEVIN (DENTIST)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VENTRUCCI
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 147TH ST W
Mailing Address - Street 2:STE 116
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7690
Mailing Address - Country:US
Mailing Address - Phone:952-432-8110
Mailing Address - Fax:952-432-4457
Practice Address - Street 1:7373 147TH ST W
Practice Address - Street 2:STE 116
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7690
Practice Address - Country:US
Practice Address - Phone:952-432-8110
Practice Address - Fax:952-432-4457
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN88351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice