Healthcare Provider Details

I. General information

NPI: 1144529322
Provider Name (Legal Business Name): KYLE DAVID SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2011
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N 87TH ST
MILWAUKEE WI
53226-3586
US

IV. Provider business mailing address

840 N 87TH ST
MILWAUKEE WI
53226-3586
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5760
  • Fax: 414-259-9115
Mailing address:
  • Phone: 414-805-5760
  • Fax: 414-259-9115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6771
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: