Provider Demographics
NPI:1467141804
Name:DENTAL CORPORATION OF KYLE POULSEN
Entity Type:Organization
Organization Name:DENTAL CORPORATION OF KYLE POULSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-335-5169
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32897 WESTERN HILLS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596
Practice Address - Country:US
Practice Address - Phone:951-335-5169
Practice Address - Fax:951-213-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty