Provider Demographics
NPI:1639730617
Name:SPACKMAN, KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SPACKMAN
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 1:98 W 100 S
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1956
Mailing Address - Country:US
Mailing Address - Phone:435-668-6479
Mailing Address - Fax:
Practice Address - Street 1:105 S 200 W
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:UT
Practice Address - Zip Code:84333-1278
Practice Address - Country:US
Practice Address - Phone:435-258-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11299320-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist