Provider Demographics
NPI:1922416114
Name:VINING, KYLE HOLMBERG (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:HOLMBERG
Last Name:VINING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:VINING
Other - Last Name:HOLMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3737 MARKET ST FL 10
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5545
Mailing Address - Country:US
Mailing Address - Phone:617-738-0806
Mailing Address - Fax:
Practice Address - Street 1:3737 MARKET ST FL 10
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5545
Practice Address - Country:US
Practice Address - Phone:617-738-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1856548122300000X
PADS043579122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist