Healthcare Provider Details

I. General information

NPI: 1972624880
Provider Name (Legal Business Name): KYLE D JEPSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 N MARKET ST 322
DALLAS TX
75202-3206
US

IV. Provider business mailing address

13525 SPRUCEWOOD DR
DALLAS TX
75240-3630
US

V. Phone/Fax

Practice location:
  • Phone: 214-757-4500
  • Fax: 214-757-4501
Mailing address:
  • Phone: 214-629-6153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22833
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13569
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00205860
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22833
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: