Healthcare Provider Details

I. General information

NPI: 1275889230
Provider Name (Legal Business Name): KATHERINE MARY SMITH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE MARY MOTZ D.D.S.

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 LOUISIANA AVE S
ST LOUIS PARK MN
55426-4121
US

IV. Provider business mailing address

1383 OZARK RDG
CORALVILLE IA
52241-3028
US

V. Phone/Fax

Practice location:
  • Phone: 952-935-9009
  • Fax:
Mailing address:
  • Phone: 605-595-4793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: