Healthcare Provider Details

I. General information

NPI: 1871564195
Provider Name (Legal Business Name): KERRY GWEN JOHNSON WINTERS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 151ST ST W
ROSEMOUNT MN
55068-1755
US

IV. Provider business mailing address

3410 151ST ST W
ROSEMOUNT MN
55068-1755
US

V. Phone/Fax

Practice location:
  • Phone: 651-322-5788
  • Fax: 651-322-4257
Mailing address:
  • Phone: 651-322-5788
  • Fax: 651-322-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD11777
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: