Healthcare Provider Details

I. General information

NPI: 1053548404
Provider Name (Legal Business Name): KYLE MATTHEW STEIN D.D.S., F.A.C.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 04/21/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 JORDAN ST
NORTH LIBERTY IA
52317-4778
US

IV. Provider business mailing address

1410 JORDAN ST
NORTH LIBERTY IA
52317-4778
US

V. Phone/Fax

Practice location:
  • Phone: 319-382-3113
  • Fax: 319-373-0023
Mailing address:
  • Phone: 319-382-3113
  • Fax: 319-373-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number08648
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: