Provider Demographics
NPI:1134737802
Name:LOHMAN, KYLE ANN
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ANN
Last Name:LOHMAN
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 1:2200 COUNTY ROAD C W STE 2210
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2551
Mailing Address - Country:US
Mailing Address - Phone:651-746-2815
Mailing Address - Fax:
Practice Address - Street 1:4155 DEAN LAKES BLVD
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2851
Practice Address - Country:US
Practice Address - Phone:952-303-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD14448122300000X
MND144481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist