Provider Demographics
NPI:1689322067
Name:BAGNELL, KYLE
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:BAGNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DOC KIMBALL WAY
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-6491
Mailing Address - Country:US
Mailing Address - Phone:406-261-6430
Mailing Address - Fax:
Practice Address - Street 1:33 DOC KIMBALL WAY
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911-6491
Practice Address - Country:US
Practice Address - Phone:406-261-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTDEN-DEN-LIC-23638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program