Provider Demographics
NPI:1396275111
Name:HOUSTON, KYLE ROSS (DMD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ROSS
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 S 1925 E
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2925
Mailing Address - Country:US
Mailing Address - Phone:801-360-3129
Mailing Address - Fax:
Practice Address - Street 1:707 E MILL RD STE 102
Practice Address - Street 2:
Practice Address - City:VINEYARD
Practice Address - State:UT
Practice Address - Zip Code:84059-5732
Practice Address - Country:US
Practice Address - Phone:801-360-3129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11888837-99251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery