Provider Demographics
NPI:1760679005
Name:KYLE E PEDERSEN DDS PC
Entity Type:Organization
Organization Name:KYLE E PEDERSEN DDS PC
Other - Org Name:DAYSPRING PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-587-4444
Mailing Address - Street 1:2570 FOXFIELD RD
Mailing Address - Street 2:STE 203
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1406
Mailing Address - Country:US
Mailing Address - Phone:630-587-4444
Mailing Address - Fax:630-587-5811
Practice Address - Street 1:2570 FOXFIELD RD
Practice Address - Street 2:STE 203
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1406
Practice Address - Country:US
Practice Address - Phone:630-587-4444
Practice Address - Fax:630-587-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021001694122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty