Healthcare Provider Details

I. General information

NPI: 1689130064
Provider Name (Legal Business Name): KYLE ANDREW SHACKELFORD RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 VALLEY SPRINGS PKWY STE E
RIVERSIDE CA
92507-0955
US

IV. Provider business mailing address

1301 W HEALD AVE
LAKE ELSINORE CA
92530-3207
US

V. Phone/Fax

Practice location:
  • Phone: 951-214-6585
  • Fax:
Mailing address:
  • Phone: 951-837-6092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number32608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: