Provider Demographics
NPI:1891785226
Name:MOEN, KATHLEEN M (DDS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MOEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310-0181
Mailing Address - Country:US
Mailing Address - Phone:320-356-7374
Mailing Address - Fax:320-356-9427
Practice Address - Street 1:300 AVON AVE S
Practice Address - Street 2:SUITE F
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310-8516
Practice Address - Country:US
Practice Address - Phone:320-356-7374
Practice Address - Fax:320-356-9427
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist