Healthcare Provider Details

I. General information

NPI: 1922499243
Provider Name (Legal Business Name): BARRETT KYLE NORDSTROM DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 HARTFORD AVE STE 101
JOHNSTON RI
02919-7100
US

IV. Provider business mailing address

18 MAPLE AVE # 117
BARRINGTON RI
02806-3560
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-7171
  • Fax: 401-331-2755
Mailing address:
  • Phone: 617-335-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDEN03481
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: