Healthcare Provider Details

I. General information

NPI: 1619350006
Provider Name (Legal Business Name): KATHERINE ROSE VAUGHAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 4TH ST NW
FARIBAULT MN
55021-5089
US

IV. Provider business mailing address

400 4TH ST NW
FARIBAULT MN
55021-5089
US

V. Phone/Fax

Practice location:
  • Phone: 507-384-6830
  • Fax: 651-431-7757
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD13579
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13579
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: