Provider Demographics
NPI:1881196616
Name:DITMARS, KYLE A (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:DITMARS
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 1:508 LAKEHURST RD STE 3B
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8000
Mailing Address - Country:US
Mailing Address - Phone:732-736-9100
Mailing Address - Fax:932-736-9500
Practice Address - Street 1:508 LAKEHURST RD STE 3B
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8000
Practice Address - Country:US
Practice Address - Phone:732-736-9100
Practice Address - Fax:732-736-9155
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02698200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist