Provider Demographics
NPI:1629137054
Name:MEHTA, KELLY KRISTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KRISTINE
Last Name:MEHTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:KRISTINE
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5212 LOGAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1022
Mailing Address - Country:US
Mailing Address - Phone:612-922-9474
Mailing Address - Fax:
Practice Address - Street 1:15785 95TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4404
Practice Address - Country:US
Practice Address - Phone:763-420-5484
Practice Address - Fax:763-420-5875
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice