Provider Demographics
NPI:1497834626
Name:DANIELSON, KIM M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:M
Last Name:DANIELSON
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 1:716 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-2406
Mailing Address - Country:US
Mailing Address - Phone:218-879-5271
Mailing Address - Fax:
Practice Address - Street 1:716 14TH ST
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-2406
Practice Address - Country:US
Practice Address - Phone:218-879-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice