MEDICARE: MRS. KELSEY MILBERT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D13062	MN

General Provider Information

NPI Number	:	1265790471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELSEY MILBERT

Provider Business Mailing Address
First Line	:	1514 E MINNESOTA ST
Second Line	:	PO BOX 607
City	:	SAINT JOSEPH
State	:	MN
Zip	:	56374-8618
Country	:	US
Telephone Number	:	320-363-7729
Fax Number	:

Provider Business Practice Location Address
First Line	:	1514 E MINNESOTA ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MN
Zip	:	56374-8618
Country	:	US
Telephone Number	:	320-363-7729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	05/30/2012

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