Provider Demographics
NPI:1659454015
Name:VAN BROCKLIN, KYLE BRUCE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:BRUCE
Last Name:VAN BROCKLIN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BOLLINGER CANYON WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4935
Mailing Address - Country:US
Mailing Address - Phone:925-735-8707
Mailing Address - Fax:
Practice Address - Street 1:525 BOLLINGER CANYON WAY STE 101
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-4935
Practice Address - Country:US
Practice Address - Phone:925-735-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery