Provider Demographics
NPI:1174015887
Name:PROHOVICH, KYLE (DR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PROHOVICH
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 FAITH RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 FAITH RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1554
Practice Address - Country:US
Practice Address - Phone:617-335-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857947122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist