Provider Demographics
NPI:1275198061
Name:DOUGLAS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 ELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 ADAMS ST STE 206
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-4914
Practice Address - Country:US
Practice Address - Phone:617-696-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist