Provider Demographics
NPI:1437633054
Name:COUNTRYMAN, KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:COUNTRYMAN
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 1:2003 NW 57TH ST UNIT 304
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-5538
Mailing Address - Country:US
Mailing Address - Phone:903-340-7943
Mailing Address - Fax:
Practice Address - Street 1:4421 LONG PRAIRIE RD STE 400
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1752
Practice Address - Country:US
Practice Address - Phone:972-691-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX349961223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics