Provider Demographics
NPI:1417479700
Name:ROSTVOLD, KIMBERLY ELLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ELLEN
Last Name:ROSTVOLD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 HOLMES AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3835
Mailing Address - Country:US
Mailing Address - Phone:218-256-8625
Mailing Address - Fax:
Practice Address - Street 1:1043 E US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3165
Practice Address - Country:US
Practice Address - Phone:218-326-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041402122300000X
MND14233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist