Provider Demographics
NPI:1508411653
Name:DETAVERNIER, KYLE EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EDWARD
Last Name:DETAVERNIER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11463 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9541
Mailing Address - Country:US
Mailing Address - Phone:248-921-2484
Mailing Address - Fax:
Practice Address - Street 1:5900 W CHESTER RD STE A
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2951
Practice Address - Country:US
Practice Address - Phone:513-942-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600250122300000X
OH30.025935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist