Provider Demographics
NPI:1598735730
Name:SANDERS, KYLE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:T
Last Name:SANDERS
Suffix:
Gender:F
Credentials:DDS
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Mailing Address - Street 1:2500 MARKETPLACE DRIVE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711
Mailing Address - Country:US
Mailing Address - Phone:404-488-2741
Mailing Address - Fax:678-662-5795
Practice Address - Street 1:3664 CLUB DR
Practice Address - Street 2:SUITE 105
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2961
Practice Address - Country:US
Practice Address - Phone:770-279-7987
Practice Address - Fax:770-279-8951
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2009-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA11929122300000X
TX250561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000842135FMedicaid