Provider Demographics
NPI:1255405478
Name:WELCH, KIM M (DDS)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:M
Last Name:WELCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:URBANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2385 TROOP DRIVE SUITE #201
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-251-2972
Mailing Address - Fax:320-255-5514
Practice Address - Street 1:2385 TROOP DRIVE SUITE #201
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-251-2972
Practice Address - Fax:320-255-5514
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113081223G0001X
MND11308122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121220600Medicaid