Provider Demographics
NPI:1689130064
Name:SHACKELFORD, KYLE ANDREW (RDH)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W HEALD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-3207
Mailing Address - Country:US
Mailing Address - Phone:951-837-6092
Mailing Address - Fax:
Practice Address - Street 1:6165 VALLEY SPRINGS PKWY STE E
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0955
Practice Address - Country:US
Practice Address - Phone:951-214-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32608124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist