Provider Demographics
NPI:1912344847
Name:BOUHANA, KYLE LOUIS (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LOUIS
Last Name:BOUHANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 GUTHRIE AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3527
Mailing Address - Country:US
Mailing Address - Phone:810-923-5674
Mailing Address - Fax:
Practice Address - Street 1:11479 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2737
Practice Address - Country:US
Practice Address - Phone:810-632-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-02
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice