Provider Demographics
NPI:1538678057
Name:BLAINE KIDDS PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:BLAINE KIDDS PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RINDELAUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-324-4270
Mailing Address - Street 1:400 2ND ST S STE 250
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1599
Mailing Address - Country:US
Mailing Address - Phone:715-808-0460
Mailing Address - Fax:
Practice Address - Street 1:1351 113TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3874
Practice Address - Country:US
Practice Address - Phone:651-324-4270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122648700Medicaid
1639126683OtherPROVIDER NPI