Provider Demographics
NPI:1508230038
Name:KYLE FUKANO DDS PLLC
Entity Type:Organization
Organization Name:KYLE FUKANO DDS PLLC
Other - Org Name:FORKS FAMILY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:FUKANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-374-2288
Mailing Address - Street 1:PO BOX 1429
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-1429
Mailing Address - Country:US
Mailing Address - Phone:360-374-2288
Mailing Address - Fax:360-374-2283
Practice Address - Street 1:421 G ST
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9025
Practice Address - Country:US
Practice Address - Phone:360-374-2288
Practice Address - Fax:360-374-2283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KYLE FUKANO DDS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-20
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000088011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE00008808OtherWA DOH