Provider Demographics
NPI:1184062739
Name:NIETEN, KATELYN MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:MARIE
Last Name:NIETEN
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:PSC 558 BOX 3539
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96375-0036
Mailing Address - Country:US
Mailing Address - Phone:989-796-4442
Mailing Address - Fax:
Practice Address - Street 1:611 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2793
Practice Address - Country:US
Practice Address - Phone:989-773-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No122300000XDental ProvidersDentist