Provider Demographics
NPI:1437802576
Name:KYLE CRANDALL DMD PLLC
Entity Type:Organization
Organization Name:KYLE CRANDALL DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-218-3985
Mailing Address - Street 1:985 S MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:TOQUERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84774-5011
Mailing Address - Country:US
Mailing Address - Phone:435-218-3985
Mailing Address - Fax:
Practice Address - Street 1:985 S MULBERRY DR
Practice Address - Street 2:
Practice Address - City:TOQUERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84774-5011
Practice Address - Country:US
Practice Address - Phone:435-218-3985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1689168577Medicaid