Provider Demographics
NPI:1003506643
Name:BADER, KYLE BENJAMIN (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:BENJAMIN
Last Name:BADER
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 1:4712 BROOK RUN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9264
Mailing Address - Country:US
Mailing Address - Phone:419-467-0994
Mailing Address - Fax:
Practice Address - Street 1:6441 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-2033
Practice Address - Country:US
Practice Address - Phone:614-834-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027112122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist