Provider Demographics
NPI:1225605223
Name:SIMMONS, KYLIE JEANENE (TTP)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:JEANENE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:TTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7604 NE 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8204
Mailing Address - Country:US
Mailing Address - Phone:877-378-4899
Mailing Address - Fax:
Practice Address - Street 1:7604 NE 5TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8204
Practice Address - Country:US
Practice Address - Phone:877-378-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATP61099840122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist