Provider Demographics
NPI:1821155573
Name:NORDBLOM, DEBORRAH JANE (DDS)
Entity Type:Individual
Prefix:
First Name:DEBORRAH
Middle Name:JANE
Last Name:NORDBLOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14990 GLAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7818
Mailing Address - Country:US
Mailing Address - Phone:952-431-5114
Mailing Address - Fax:952-431-3576
Practice Address - Street 1:14990 GLAZIER AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7818
Practice Address - Country:US
Practice Address - Phone:952-431-5114
Practice Address - Fax:952-431-3576
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10101122300000X
MN101011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000724372OtherUNITED CONCORDIA