Provider Demographics
NPI:1417484296
Name:WASSERMAN, KYLIE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 N HWY 97 STE 150
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7569
Mailing Address - Country:US
Mailing Address - Phone:541-797-9136
Mailing Address - Fax:458-202-2218
Practice Address - Street 1:3081 N HIGHWAY 97 STE 150
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7569
Practice Address - Country:US
Practice Address - Phone:541-797-9136
Practice Address - Fax:458-202-2218
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD107891223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1417484296OtherDENTIST, HEALTH CARE