Provider Demographics
NPI:1467485466
Name:KUNTZ, KYLE EDWIN (OD OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EDWIN
Last Name:KUNTZ
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601
Mailing Address - Country:US
Mailing Address - Phone:406-442-7130
Mailing Address - Fax:406-442-7317
Practice Address - Street 1:1234 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601
Practice Address - Country:US
Practice Address - Phone:406-442-7130
Practice Address - Fax:406-442-7317
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0487045Medicaid
T89240Medicare UPIN
MT000002844Medicare ID - Type Unspecified