Provider Demographics
NPI:1780436485
Name:NIEMANN, KAITLYN JEAN (RDH, DT)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JEAN
Last Name:NIEMANN
Suffix:
Gender:F
Credentials:RDH, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6478 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3716
Mailing Address - Country:US
Mailing Address - Phone:612-875-4522
Mailing Address - Fax:
Practice Address - Street 1:636 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2164
Practice Address - Country:US
Practice Address - Phone:612-746-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT175125J00000X
MN11634124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist