Provider Demographics
NPI:1629207717
Name:FANT, KYLA RENEA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLA
Middle Name:RENEA
Last Name:FANT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7166 W CUSTER AVE
Mailing Address - Street 2:#C-327
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-2781
Mailing Address - Country:US
Mailing Address - Phone:512-585-7395
Mailing Address - Fax:
Practice Address - Street 1:2020 WADSWORTH BLVD
Practice Address - Street 2:STE 9
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5728
Practice Address - Country:US
Practice Address - Phone:303-431-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246471223G0001X
CO99091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice