Provider Demographics
NPI:1053372656
Name:ROBERTS, KRISTIE ANN (DDS)
Entity type:Individual
Prefix:MS
First Name:KRISTIE
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:KRISTIE
Other - Middle Name:ANN
Other - Last Name:BEDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1105 HILLSIDE AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063
Mailing Address - Country:US
Mailing Address - Phone:320-629-2789
Mailing Address - Fax:320-629-1330
Practice Address - Street 1:1105 HILLSIDE AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:320-629-2789
Practice Address - Fax:320-629-1330
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND108701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP28208OtherHEALTH PARTNERS