Provider Demographics
NPI:1649213547
Name:MCDONALD, KYLE RICHARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:RICHARD
Last Name:MCDONALD
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:PO BOX 1399
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-1399
Mailing Address - Country:US
Mailing Address - Phone:209-586-1061
Mailing Address - Fax:209-586-1078
Practice Address - Street 1:17961 PLATEAU RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8900
Practice Address - Country:US
Practice Address - Phone:209-586-1061
Practice Address - Fax:209-586-1078
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice