Individual
DR. KYLE D TIDSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
7373 FRANCE AVE S, SUITE 602, EDINA, MN 55435-4534
(952) 835-5003
(952) 835-9598
Mailing address
7373 FRANCE AVE S, SUITE 602, EDINA, MN 55435-4534
(952) 835-5003
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
D10340
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
41677TI
BCBS NUMBER
FM
01
—
86-17290
MEDICA NUMBER
MN
Enumeration date
02/07/2006
Last updated
07/08/2007
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