Provider Demographics
NPI:1821667635
Name:KASTELIC, KELLE LOUISE (DMD)
Entity type:Individual
Prefix:
First Name:KELLE
Middle Name:LOUISE
Last Name:KASTELIC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 4TH LN SE APT 307
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-4439
Mailing Address - Country:US
Mailing Address - Phone:615-300-1490
Mailing Address - Fax:
Practice Address - Street 1:BRAHAM FAMILY DENTAL
Practice Address - Street 2:302 MAIN ST N
Practice Address - City:BRAHAM
Practice Address - State:MN
Practice Address - Zip Code:55006
Practice Address - Country:US
Practice Address - Phone:320-396-4417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND147111223G0001X
WI6001706-151223G0001X
CODEN.00205742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice