Provider Demographics
NPI:1396425021
Name:FLAVIN, KEELEY (MSDH, BSDH)
Entity type:Individual
Prefix:
First Name:KEELEY
Middle Name:
Last Name:FLAVIN
Suffix:
Gender:F
Credentials:MSDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14111 ROSEWOOD LN N
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:55327-9720
Mailing Address - Country:US
Mailing Address - Phone:952-457-0457
Mailing Address - Fax:
Practice Address - Street 1:825 NICOLLET MALL STE 1737
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2704
Practice Address - Country:US
Practice Address - Phone:612-332-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH10122124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist