Provider Demographics
NPI:1417479700
Name:ROSTVOLD, KIMBERLY ELLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ELLEN
Last Name:ROSTVOLD
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 1:3528 HOLMES AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3835
Mailing Address - Country:US
Mailing Address - Phone:218-256-8625
Mailing Address - Fax:
Practice Address - Street 1:4419 AIR BASE RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1847
Practice Address - Country:US
Practice Address - Phone:218-728-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14233122300000X, 1223P0221X
PADS041402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist