Healthcare Provider Details

I. General information

NPI: 1891785226
Provider Name (Legal Business Name): KATHLEEN M MOEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 AVON AVE S SUITE F
AVON MN
56310-8516
US

IV. Provider business mailing address

PO BOX 181
AVON MN
56310-0181
US

V. Phone/Fax

Practice location:
  • Phone: 320-356-7374
  • Fax: 320-356-9427
Mailing address:
  • Phone: 320-356-7374
  • Fax: 320-356-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10962
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: