Provider Demographics
NPI:1407146764
Name:SAMPLES, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SAMPLES
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 1:1411A N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1945
Mailing Address - Country:US
Mailing Address - Phone:660-542-6066
Mailing Address - Fax:660-646-3887
Practice Address - Street 1:821 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2102
Practice Address - Country:US
Practice Address - Phone:660-826-4774
Practice Address - Fax:660-826-1300
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2011015414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program