Provider Demographics
NPI:1285647677
Name:WHEELER, KYLE WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:WESLEY
Last Name:WHEELER
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 1:1084 THOMAS JEFFERSON RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2275
Mailing Address - Country:US
Mailing Address - Phone:434-385-6398
Mailing Address - Fax:
Practice Address - Street 1:1084 THOMAS JEFFERSON RD
Practice Address - Street 2:SUITE 5
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2275
Practice Address - Country:US
Practice Address - Phone:434-385-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007813562Medicaid
VA9178611OtherDORAL SMILES FOR CHILDREN