Provider Demographics
NPI:1760820500
Name:HOMERSTAD, KYNE ARLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYNE
Middle Name:ARLEN
Last Name:HOMERSTAD
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 1:2521 SOUTHMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77502-1451
Mailing Address - Country:US
Mailing Address - Phone:713-477-1414
Mailing Address - Fax:
Practice Address - Street 1:2521 SOUTHMORE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-1451
Practice Address - Country:US
Practice Address - Phone:713-477-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX290271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice