Provider Demographics
NPI:1790346013
Name:PETT, KYLE M (DMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:PETT
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 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1051
Mailing Address - Country:US
Mailing Address - Phone:541-479-6393
Mailing Address - Fax:541-479-6489
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1051
Practice Address - Country:US
Practice Address - Phone:541-479-6393
Practice Address - Fax:541-479-6489
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500764913Medicaid