Healthcare Provider Details

I. General information

NPI: 1669192902
Provider Name (Legal Business Name): KYLE VILAYSANE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1193 PINEVIEW DR STE A
MORGANTOWN WV
26505-3395
US

IV. Provider business mailing address

2962 SHAMROCK DR
ELGIN IL
60124-4354
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-8250
  • Fax:
Mailing address:
  • Phone: 224-717-1798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4883
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: