Provider Demographics
NPI:1073862819
Name:KENNETH B WEDDELL PLLC
Entity Type:Organization
Organization Name:KENNETH B WEDDELL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WEDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-884-7706
Mailing Address - Street 1:8900 PENN AVE S STE 211
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2068
Mailing Address - Country:US
Mailing Address - Phone:952-884-7706
Mailing Address - Fax:952-881-6006
Practice Address - Street 1:8900 PENN AVE S STE 211
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-2068
Practice Address - Country:US
Practice Address - Phone:952-884-7706
Practice Address - Fax:952-881-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND126191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104884147OtherNPI
1104884147OtherNPI