Provider Demographics
NPI:1093092629
Name:HIBBERT, KYLE LANCE (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:LANCE
Last Name:HIBBERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:WINDOW ROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86515-0781
Mailing Address - Country:US
Mailing Address - Phone:307-696-3105
Mailing Address - Fax:
Practice Address - Street 1:US 191 & SR 264
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505-7415
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT829152W00000X
AZOPT-002332152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist