Provider Demographics
NPI:1063574358
Name:KINNEBERG, BARRY JAY SR
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:JAY
Last Name:KINNEBERG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BARRY
Other - Middle Name:
Other - Last Name:KINNEBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:436 ASHLAND AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2056
Mailing Address - Country:US
Mailing Address - Phone:651-227-7653
Mailing Address - Fax:
Practice Address - Street 1:436 ASHLAND AVE APT 6
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2056
Practice Address - Country:US
Practice Address - Phone:651-227-7653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist