MEDICARE: KERRY GWEN JOHNSON WINTERS DDS

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	1223P0221X	Pediatric Dentistry	D11777	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871564195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY GWEN JOHNSON WINTERS DDS

Provider Business Mailing Address
First Line	:	3410 151ST ST W
Second Line	:
City	:	ROSEMOUNT
State	:	MN
Zip	:	55068-1755
Country	:	US
Telephone Number	:	651-322-5788
Fax Number	:	651-322-4257

Provider Business Practice Location Address
First Line	:	3410 151ST ST W
Second Line	:
City	:	ROSEMOUNT
State	:	MN
Zip	:	55068-1755
Country	:	US
Telephone Number	:	651-322-5788
Fax Number	:	651-322-4257

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

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	11/30/2012

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