Provider Demographics
NPI:1023760501
Name:MCNULTY, KYLE (DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MCNULTY
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 1:2179 BELLA CASA ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0715
Mailing Address - Country:US
Mailing Address - Phone:831-359-1148
Mailing Address - Fax:
Practice Address - Street 1:5041 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1786
Practice Address - Country:US
Practice Address - Phone:831-359-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107652122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty