Provider Demographics
NPI:1619155371
Name:KYLE L. SERFOSS, DDS, PLLC
Entity Type:Organization
Organization Name:KYLE L. SERFOSS, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:LANDON
Authorized Official - Last Name:SERFOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-323-0763
Mailing Address - Street 1:810 W GARY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-2720
Mailing Address - Country:US
Mailing Address - Phone:580-323-0763
Mailing Address - Fax:580-323-5532
Practice Address - Street 1:810 W GARY BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-2720
Practice Address - Country:US
Practice Address - Phone:580-323-0763
Practice Address - Fax:580-323-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200090120AMedicaid