Healthcare Provider Details

I. General information

NPI: 1265790471
Provider Name (Legal Business Name): MRS. KELSEY MILBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 E MINNESOTA ST
SAINT JOSEPH MN
56374-8618
US

IV. Provider business mailing address

1514 E MINNESOTA ST PO BOX 607
SAINT JOSEPH MN
56374-8618
US

V. Phone/Fax

Practice location:
  • Phone: 320-363-7729
  • Fax:
Mailing address:
  • Phone: 320-363-7729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD13062
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: