Provider Demographics
NPI:1811556509
Name:RADNER, KATELYN MICHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:MICHELLE
Last Name:RADNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 CONNERY CT
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3137
Mailing Address - Country:US
Mailing Address - Phone:727-599-4841
Mailing Address - Fax:
Practice Address - Street 1:3680 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2608
Practice Address - Country:US
Practice Address - Phone:813-820-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24201122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist