Provider Demographics
NPI:1659343119
Name:TIDSTROM, KYLE D (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:D
Last Name:TIDSTROM
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 1:7373 FRANCE AVE S
Mailing Address - Street 2:SUITE 602
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4534
Mailing Address - Country:US
Mailing Address - Phone:952-835-5003
Mailing Address - Fax:
Practice Address - Street 1:7373 FRANCE AVE S
Practice Address - Street 2:SUITE 602
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4534
Practice Address - Country:US
Practice Address - Phone:952-835-5003
Practice Address - Fax:952-835-9598
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM41677TIOtherBCBS NUMBER
MN86-17290OtherMEDICA NUMBER
MNT78373Medicare UPIN