Healthcare Provider Details

I. General information

NPI: 1811720162
Provider Name (Legal Business Name): KYLE PROCTOR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 SYLVA LN STE K2
SONORA CA
95370-5969
US

IV. Provider business mailing address

PO BOX 535
JAMESTOWN CA
95327-0535
US

V. Phone/Fax

Practice location:
  • Phone: 209-536-8600
  • Fax:
Mailing address:
  • Phone: 209-984-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: