Provider Demographics
NPI:1497243190
Name:JONNA, KYLE R
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:JONNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1242
Mailing Address - Country:US
Mailing Address - Phone:248-840-2058
Mailing Address - Fax:
Practice Address - Street 1:30955 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0800
Practice Address - Country:US
Practice Address - Phone:248-397-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29016003431223G0001X
390200000X
MI29016003431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program