Provider Demographics
NPI:1184729436
Name:BOMSTAD, KRIS CLIFTON (DDS)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:CLIFTON
Last Name:BOMSTAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343
Mailing Address - Country:US
Mailing Address - Phone:952-938-7746
Mailing Address - Fax:952-938-1511
Practice Address - Street 1:911 1ST ST N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:952-938-7746
Practice Address - Fax:952-938-1511
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice