Provider Demographics
NPI:1770570251
Name:VAN, KYLE H (DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:H
Last Name:VAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:H
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:420 NW 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2972
Mailing Address - Country:US
Mailing Address - Phone:503-702-3565
Mailing Address - Fax:503-533-4116
Practice Address - Street 1:16755 SW BASELINE RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4241
Practice Address - Country:US
Practice Address - Phone:503-533-4001
Practice Address - Fax:503-533-4116
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice