=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275198061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE DOUGLAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2019
-----------------------------------------------------
Last Update Date | 06/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 W CENTER ST STE 1
-----------------------------------------------------
City | WEST BRIDGEWATER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02379-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-894-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 ADAMS ST APT 43
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02122-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1858619
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------