Provider Demographics
NPI:1518015064
Name:NORDBERG, KIM DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:DAVID
Last Name:NORDBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11023 CANYON ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373
Mailing Address - Country:US
Mailing Address - Phone:253-535-6666
Mailing Address - Fax:253-535-5432
Practice Address - Street 1:11023 CANYON ROAD EAST
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373
Practice Address - Country:US
Practice Address - Phone:253-535-6666
Practice Address - Fax:253-535-5432
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist