Provider Demographics
NPI:1982993267
Name:SHULL, KYLE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:M
Last Name:SHULL
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 1:2601 RANGE LINE ST STE 111
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-1618
Mailing Address - Country:US
Mailing Address - Phone:573-355-5870
Mailing Address - Fax:573-355-5887
Practice Address - Street 1:2601 RANGE LINE ST STE 111
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202
Practice Address - Country:US
Practice Address - Phone:573-355-5870
Practice Address - Fax:573-355-5887
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011016320122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist