Provider Demographics
NPI:1407951973
Name:FUKANO, KYLE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:T
Last Name:FUKANO
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:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-0729
Mailing Address - Country:US
Mailing Address - Phone:360-331-5211
Mailing Address - Fax:360-331-5212
Practice Address - Street 1:1684 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-5211
Practice Address - Fax:360-331-5212
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE00008801OtherDDS LICENSE
WADE00008801OtherDDS LICENSE