Healthcare Provider Details

I. General information

NPI: 1922980879
Provider Name (Legal Business Name): KACI THEURER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 HOLLY LN
MANKATO MN
56001-5422
US

IV. Provider business mailing address

309 HOLLY LN
MANKATO MN
56001-5422
US

V. Phone/Fax

Practice location:
  • Phone: 507-388-2120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH11781
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT181
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: