Provider Demographics
NPI:1780706275
Name:KIM-WEROHA, NELLIE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:NELLIE
Middle Name:
Last Name:KIM-WEROHA
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 BROADWAY AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904
Mailing Address - Country:US
Mailing Address - Phone:507-288-4427
Mailing Address - Fax:507-288-8497
Practice Address - Street 1:1705 BROADWAY AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904
Practice Address - Country:US
Practice Address - Phone:507-288-4427
Practice Address - Fax:507-288-8497
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND124831223S0112X, 1223X0400X
MO20040135911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO37266018OtherBCBS OF KCPROVIDER NUMBER