Healthcare Provider Details

I. General information

NPI: 1801087879
Provider Name (Legal Business Name): KRISTA L. KUKARANS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 5TH ST SE
COOK MN
55723-9702
US

IV. Provider business mailing address

20 5TH ST SE
COOK MN
55723-9702
US

V. Phone/Fax

Practice location:
  • Phone: 218-666-5941
  • Fax: 218-666-5099
Mailing address:
  • Phone: 218-666-5941
  • Fax: 218-666-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14505
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6157
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: