Healthcare Provider Details

I. General information

NPI: 1629652425
Provider Name (Legal Business Name): BAILEY KENT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 51ST ST N
LAKE ELMO MN
55042-8594
US

IV. Provider business mailing address

9700 51ST ST N
LAKE ELMO MN
55042-8594
US

V. Phone/Fax

Practice location:
  • Phone: 651-278-5703
  • Fax:
Mailing address:
  • Phone: 651-278-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number75705
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: