Provider Demographics
NPI:1356975296
Name:GRANT, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GRANT
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 1:1700 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2335
Mailing Address - Country:US
Mailing Address - Phone:702-774-5175
Mailing Address - Fax:702-774-2812
Practice Address - Street 1:1700 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2335
Practice Address - Country:US
Practice Address - Phone:702-774-5175
Practice Address - Fax:702-774-2812
Is Sole Proprietor?:No
Enumeration Date:2020-03-01
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-531-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice