Healthcare Provider Details

I. General information

NPI: 1114514205
Provider Name (Legal Business Name): CAROUSEL PEDIATRIC DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15160 FOLIAGE AVE STE 110
APPLE VALLEY MN
55124-5916
US

IV. Provider business mailing address

15160 FOLIAGE AVE STE 110
APPLE VALLEY MN
55124-5916
US

V. Phone/Fax

Practice location:
  • Phone: 952-715-6177
  • Fax:
Mailing address:
  • Phone: 952-715-6177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE NORDEEN
Title or Position: OWNER
Credential: DDS
Phone: 952-715-6177