Provider Demographics
NPI:1215280144
Name:SCHWARTZBAUER, KELLY RAE
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RAE
Last Name:SCHWARTZBAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6670 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:277 3RD ST N
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:MN
Practice Address - Zip Code:55003-1028
Practice Address - Country:US
Practice Address - Phone:651-439-2352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130391223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice