Provider Demographics
NPI:1114514205
Name:CAROUSEL PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:CAROUSEL PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-715-6177
Mailing Address - Street 1:15160 FOLIAGE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5916
Mailing Address - Country:US
Mailing Address - Phone:952-715-6177
Mailing Address - Fax:
Practice Address - Street 1:15160 FOLIAGE AVE STE 110
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5916
Practice Address - Country:US
Practice Address - Phone:952-715-6177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty