Provider Demographics
NPI:1184251092
Name:KITASOE, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KITASOE
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 1:825 OAK GROVE AVE STE C501
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4427
Mailing Address - Country:US
Mailing Address - Phone:650-323-5211
Mailing Address - Fax:
Practice Address - Street 1:825 OAK GROVE AVE STE C501
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4427
Practice Address - Country:US
Practice Address - Phone:650-323-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1067031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program