Provider Demographics
NPI:1225689060
Name:JOHNSON-HETCHLER, KYLIE MIRANDA (ADT)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MIRANDA
Last Name:JOHNSON-HETCHLER
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9395 WELLINGTON LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4150
Mailing Address - Country:US
Mailing Address - Phone:763-381-2985
Mailing Address - Fax:
Practice Address - Street 1:3650 BRADDOCK AVE NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-3672
Practice Address - Country:US
Practice Address - Phone:763-270-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH10758124Q00000X
MNDT128125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist