Healthcare Provider Details

I. General information

NPI: 1225689060
Provider Name (Legal Business Name): KYLIE MIRANDA ANDERSON ADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 BRADDOCK AVE NE
BUFFALO MN
55313-3672
US

IV. Provider business mailing address

9395 WELLINGTON LN N
MAPLE GROVE MN
55369-4150
US

V. Phone/Fax

Practice location:
  • Phone: 763-270-6900
  • Fax:
Mailing address:
  • Phone: 763-381-2985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH10758
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT128
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: