Provider Demographics
NPI:1689168577
Name:CRANDALL, KYLE LAWRENCE (DMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LAWRENCE
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2954 CARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79916
Mailing Address - Country:US
Mailing Address - Phone:915-742-3303
Mailing Address - Fax:
Practice Address - Street 1:2954 CARRINGTON RD
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice