Provider Demographics
NPI:1982194098
Name:WILMES, KRISTAL SUE
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:SUE
Last Name:WILMES
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 1:197 N TYLER ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-1160
Mailing Address - Country:US
Mailing Address - Phone:507-380-0127
Mailing Address - Fax:
Practice Address - Street 1:197 N TYLER ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-1160
Practice Address - Country:US
Practice Address - Phone:507-380-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice