Healthcare Provider Details

I. General information

NPI: 1407146764
Provider Name (Legal Business Name): KYLE SAMPLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 WESTWOOD DR
SEDALIA MO
65301-2102
US

IV. Provider business mailing address

1411A N JEFFERSON ST
CARROLLTON MO
64633-1945
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-4774
  • Fax: 660-826-1300
Mailing address:
  • Phone: 660-542-6066
  • Fax: 660-646-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011015414
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: