Healthcare Provider Details

I. General information

NPI: 1780198010
Provider Name (Legal Business Name): GOLDEN VALLEY KIDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7575 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55427-4562
US

IV. Provider business mailing address

5128 TIFTON DR
EDINA MN
55439-1457
US

V. Phone/Fax

Practice location:
  • Phone: 763-222-1299
  • Fax:
Mailing address:
  • Phone: 612-419-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD11961
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD11564
License Number StateMN

VIII. Authorized Official

Name: DR. ADENA FERN BORODKIN
Title or Position: PEDIATRIC DENTIST
Credential: DDS, MS
Phone: 763-222-1299