Healthcare Provider Details

I. General information

NPI: 1053608752
Provider Name (Legal Business Name): KYLE KLOOSTER MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7633 E JEFFERSON AVE SUITE 70
DETROIT MI
48214-3730
US

IV. Provider business mailing address

7633 E JEFFERSON AVE SUITE 70
DETROIT MI
48214-3730
US

V. Phone/Fax

Practice location:
  • Phone: 313-499-4775
  • Fax: 313-499-4953
Mailing address:
  • Phone: 313-499-4775
  • Fax: 313-499-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901020443
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: