Provider Demographics
NPI:1629459102
Name:GOPLEN, MARISSA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ANN
Last Name:GOPLEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANN
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1317 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1317 GROVE AVE
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1708
Practice Address - Country:US
Practice Address - Phone:320-269-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135481223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice