Provider Demographics
NPI:1265686463
Name:HACKNEY, KYLE HOUSTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:HOUSTON
Last Name:HACKNEY
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 1:1051 SE STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7117
Mailing Address - Country:US
Mailing Address - Phone:360-426-1676
Mailing Address - Fax:360-427-4303
Practice Address - Street 1:1051 SE STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7117
Practice Address - Country:US
Practice Address - Phone:360-426-1676
Practice Address - Fax:360-427-4303
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60035243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist