Provider Demographics
NPI:1982071379
Name:POULSEN, KYLE DOUGLASS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DOUGLASS
Last Name:POULSEN
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 1:29950 HAUN RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6527
Mailing Address - Country:US
Mailing Address - Phone:951-679-1667
Mailing Address - Fax:951-679-8664
Practice Address - Street 1:29950 HAUN RD STE 302
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-6527
Practice Address - Country:US
Practice Address - Phone:951-679-1667
Practice Address - Fax:951-679-8664
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA649551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice