Provider Demographics
NPI:1871564195
Name:WINTERS, KERRY GWEN JOHNSON (DDS)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:GWEN JOHNSON
Last Name:WINTERS
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 1:3410 151ST ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-1755
Mailing Address - Country:US
Mailing Address - Phone:651-322-5788
Mailing Address - Fax:651-322-4257
Practice Address - Street 1:3410 151ST ST W
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1755
Practice Address - Country:US
Practice Address - Phone:651-322-5788
Practice Address - Fax:651-322-4257
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND117771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN380650200Medicaid