Provider Demographics
NPI:1740404797
Name:MOLLDREM, KEVIN DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DANIEL
Last Name:MOLLDREM
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 1:800 PRAIRIE CENTER DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7328
Mailing Address - Country:US
Mailing Address - Phone:952-974-5116
Mailing Address - Fax:
Practice Address - Street 1:800 PRAIRIE CENTER DR
Practice Address - Street 2:SUITE 250
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7328
Practice Address - Country:US
Practice Address - Phone:952-974-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1326173279OtherOFFICE NPI