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NPI Code Detail

MEDICARE: MS. SHARON K KETTLER RDH

MEDICARE: MS. SHARON K KETTLER RDH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1124Q00000XDental HygienistH5650MN

General Provider Information

NPI Number : 1083628515
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. SHARON K KETTLER RDH
Provider Business Mailing Address
First Line : 2330 SIOUX TRL NW
Second Line :
City : PRIOR LAKE
State : MN
Zip : 55372-9077
Country : US
Telephone Number : 952-496-6148
Fax Number : 952-233-4224
Provider Business Practice Location Address
First Line : 2330 SIOUX TRL NW
Second Line :
City : PRIOR LAKE
State : MN
Zip : 55372-9077
Country : US
Telephone Number : 952-496-6148
Fax Number : 952-233-4224
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2006
Last Update Date : 07/08/2007

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