Provider Demographics
NPI:1265886352
Name:YAMAMOTO, KYLE (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:YAMAMOTO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22410 HAWTHORNE BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2594
Mailing Address - Country:US
Mailing Address - Phone:310-373-2238
Mailing Address - Fax:
Practice Address - Street 1:22410 HAWTHORNE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2594
Practice Address - Country:US
Practice Address - Phone:310-373-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1009531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFY6419104OtherDEA LICENSE