Provider Demographics
NPI:1053977736
Name:KOEHLER, KRISTA JEAN (DDS)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JEAN
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 WASHINGTON AVE SE APT 911
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-4111
Mailing Address - Country:US
Mailing Address - Phone:715-207-2692
Mailing Address - Fax:
Practice Address - Street 1:6411 RICHFIELD PKWY
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-6400
Practice Address - Country:US
Practice Address - Phone:612-869-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND14180OtherMN BOARD OF DENTISTRY