Provider Demographics
NPI:1679864078
Name:IVERSON, KATHLEEN ANN (LDH)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:MCDONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDH
Mailing Address - Street 1:1670 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1201
Mailing Address - Country:US
Mailing Address - Phone:651-925-8400
Mailing Address - Fax:651-925-8439
Practice Address - Street 1:1670 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1201
Practice Address - Country:US
Practice Address - Phone:651-925-8400
Practice Address - Fax:651-925-8439
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH3571124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist