Provider Demographics
NPI:1841084878
Name:MAYFIELD, KYLE ROBERT
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:MAYFIELD
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:W6589 FIRELANE 7
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-9418
Mailing Address - Country:US
Mailing Address - Phone:920-750-8278
Mailing Address - Fax:
Practice Address - Street 1:2101 E CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4743
Practice Address - Country:US
Practice Address - Phone:920-731-1550
Practice Address - Fax:920-731-4403
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001797-151223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program