Healthcare Provider Details

I. General information

NPI: 1083628515
Provider Name (Legal Business Name): SHARON K KETTLER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 SIOUX TRL NW
PRIOR LAKE MN
55372-9077
US

IV. Provider business mailing address

2330 SIOUX TRL NW
PRIOR LAKE MN
55372-9077
US

V. Phone/Fax

Practice location:
  • Phone: 952-496-6148
  • Fax: 952-233-4224
Mailing address:
  • Phone: 952-496-6148
  • Fax: 952-233-4224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5650
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: