MEDICARE: DR. KELLY K KOEHNEN D.D.S.

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	10985	MN

General Provider Information

NPI Number	:	1285639815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY K KOEHNEN D.D.S.

Provider Business Mailing Address
First Line	:	1406 W LAKE ST
Second Line	:	STE 100
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2653
Country	:	US
Telephone Number	:	612-827-3736
Fax Number	:	612-821-9626

Provider Business Practice Location Address
First Line	:	1406 W LAKE ST
Second Line	:	STE 100
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2653
Country	:	US
Telephone Number	:	612-827-3736
Fax Number	:	612-821-9626

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/08/2007

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