Provider Demographics
NPI:1922081355
Name:O'NEAL, KYLE H
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:H
Last Name:O'NEAL
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 1:7011 EVANS TOWN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4315
Mailing Address - Country:US
Mailing Address - Phone:706-724-8735
Mailing Address - Fax:
Practice Address - Street 1:7011 EVANS TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4315
Practice Address - Country:US
Practice Address - Phone:706-724-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA110541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG1054Medicaid
SC000528734BMedicaid
U30369Medicare UPIN
SCZG1054Medicaid