Provider Demographics
NPI:1689842726
Name:BOTHUN, KRISTIN HELEN
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:HELEN
Last Name:BOTHUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 HAWTHORN AVE EAST
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4183
Mailing Address - Country:US
Mailing Address - Phone:651-774-2959
Mailing Address - Fax:
Practice Address - Street 1:828 HAWTHORNE ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3252
Practice Address - Country:US
Practice Address - Phone:651-774-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC12443OtherLICENSE NUMBER