Provider Demographics
NPI:1437767555
Name:NOVOTNY, KYLE STEPHEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:STEPHEN
Last Name:NOVOTNY
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 1:12265 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3961
Mailing Address - Country:US
Mailing Address - Phone:763-757-1323
Mailing Address - Fax:
Practice Address - Street 1:12265 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3961
Practice Address - Country:US
Practice Address - Phone:763-757-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice