Provider Demographics
NPI:1275848111
Name:WENTZ, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WENTZ
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 1:227 16TH ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4675
Mailing Address - Country:US
Mailing Address - Phone:701-225-0767
Mailing Address - Fax:701-225-7123
Practice Address - Street 1:227 16TH ST W STE 100
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4675
Practice Address - Country:US
Practice Address - Phone:701-225-0767
Practice Address - Fax:701-225-7123
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1121225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist