Basic Information
| Provider Information | |||||||||
| NPI: | 1457984783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURPHY | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4325 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558072730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187221497 | ||||||||
| FaxNumber: | 2186246594 | ||||||||
| Practice Location | |||||||||
| Address1: | 4325 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558072730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187221497 | ||||||||
| FaxNumber: | 2186246594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2020 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H4363 | MN | Y | Dental Providers | Dental Hygienist |
No ID Information.