Provider Demographics
NPI:1174823298
Name:KYSER, KOSTACE LESLIE (RDH)
Entity Type:Individual
Prefix:MR
First Name:KOSTACE
Middle Name:LESLIE
Last Name:KYSER
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 COMMONWEALTH
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216
Mailing Address - Country:US
Mailing Address - Phone:716-297-0798
Mailing Address - Fax:716-297-0998
Practice Address - Street 1:78 COMMONWEALTH
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216
Practice Address - Country:US
Practice Address - Phone:716-297-0798
Practice Address - Fax:716-297-0998
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023835-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023835-1OtherNEW YORK STATE LICENSE