Provider Demographics
NPI:1346810231
Name:O'HARA, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:O'HARA
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 1:442 SW UMATILLA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:
Practice Address - Street 1:913 A ST
Practice Address - Street 2:
Practice Address - City:MYRTLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97458-1334
Practice Address - Country:US
Practice Address - Phone:541-559-5000
Practice Address - Fax:541-516-4035
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11466122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist