Healthcare Provider Details

I. General information

NPI: 1821884982
Provider Name (Legal Business Name): KYLE COUSINEAU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11696 HAMILTON LAKE AVE
LAS VEGAS NV
89138-6402
US

IV. Provider business mailing address

11696 HAMILTON LAKE AVE
LAS VEGAS NV
89138-6402
US

V. Phone/Fax

Practice location:
  • Phone: 702-918-4327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7684
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: