Provider Demographics
NPI:1982275202
Name:DETMER, KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DETMER
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 1:8930 W SUNCREST ST APT 603
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4069
Mailing Address - Country:US
Mailing Address - Phone:316-617-7184
Mailing Address - Fax:
Practice Address - Street 1:404 S EDGEMOOR ST STE 320
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1632
Practice Address - Country:US
Practice Address - Phone:316-559-3993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS619061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice