Healthcare Provider Details

I. General information

NPI: 1689168577
Provider Name (Legal Business Name): KYLE LAWRENCE CRANDALL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 CARRINGTON RD
APO AA
79916
US

IV. Provider business mailing address

2954 CARRINGTON RD
FORT BLISS TX
79916
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-3303
  • Fax:
Mailing address:
  • Phone: 915-742-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34248
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: