Active NPI
Kyle E Pedersen, D.D.S.
- Pediatric Dentistry
- St Charles, IL
National Provider Identifier
1619092905
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- Practice address
- 2560 Foxfield Rd
Suite 190
St Charles, IL 60174-5797 - Phone
- (630) 587-4444
- NPI assigned
- Mar 19, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | IL | Primary |
Addresses
Primary practice location
2560 Foxfield Rd
Suite 190
St Charles, IL 60174-5797
Mailing address
2560 Foxfield Rd
Suite 190
St Charles, IL 60174-5797
Phone (630) 587-4444
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 021.001694 | IL | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174262400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1619092905",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2560 FOXFIELD RD",
"address_2": "SUITE 190",
"city": "ST CHARLES",
"state": "IL",
"postal_code": "601745797",
"telephone_number": "630-587-4444"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2560 FOXFIELD RD",
"address_2": "SUITE 190",
"city": "ST CHARLES",
"state": "IL",
"postal_code": "601745797",
"telephone_number": "630-587-4444"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSEN",
"first_name": "KYLE",
"middle_name": "E",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-19",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in St Charles, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.