Provider Demographics
NPI:1578661344
Name:WEEDON, KYLE ERNEST (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ERNEST
Last Name:WEEDON
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 1:115 NORTH NEWSOM ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-2131
Mailing Address - Country:US
Mailing Address - Phone:903-569-5818
Mailing Address - Fax:903-569-5818
Practice Address - Street 1:115 NORTH NEWSOM ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-2131
Practice Address - Country:US
Practice Address - Phone:903-569-5818
Practice Address - Fax:903-569-5818
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist