Provider Demographics
NPI:1699834150
Name:THELEN, KRISTA MONIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:MONIQUE
Last Name:THELEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:10054 JAMES AVE NE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-4312
Mailing Address - Country:US
Mailing Address - Phone:612-743-3657
Mailing Address - Fax:
Practice Address - Street 1:11269 JEFFERSON HWY N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3123
Practice Address - Country:US
Practice Address - Phone:763-421-5206
Practice Address - Fax:763-421-8320
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
MND119691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice