Provider Demographics
NPI:1558815811
Name:IVEY, KYLE (DMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7324
Mailing Address - Country:US
Mailing Address - Phone:910-643-2196
Mailing Address - Fax:
Practice Address - Street 1:5424 REILLY ROAD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28308
Practice Address - Country:US
Practice Address - Phone:910-570-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04245122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist