Basic Information
| Provider Information | |||||||||
| NPI: | 1669583407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOTZBUECHER | ||||||||
| FirstName: | KURTIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 FRANCE AVE S | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522249771 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Practice Location | |||||||||
| Address1: | 8711 E POINT DOUGLAS RD S | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550165000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513799892 | ||||||||
| FaxNumber: | 6513799893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9055 | MN | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3002233-00 | 05 | MN | MEDICAID |