Provider Demographics
NPI:1518571587
Name:VANDEN BROECK, KYRA (DDS)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:VANDEN BROECK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KYRA
Other - Middle Name:
Other - Last Name:GARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3703 HIGHLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8328
Mailing Address - Country:US
Mailing Address - Phone:505-801-8154
Mailing Address - Fax:
Practice Address - Street 1:800 E 30TH ST BLDG 3
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9407
Practice Address - Country:US
Practice Address - Phone:505-327-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist