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General NPI Number Information
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NPI Number | 1508230038
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Entity Type | Organization
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Legal Business Name | KYLE FUKANO DDS PLLC
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Dates
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Enumeration Date | 11/20/2015
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Last Update Date | 01/26/2016
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Provider Practice Location Address
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Address Line | 421 G ST
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City | FORKS
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State | WA
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Zip | 98331-9025
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Country | US
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Telephone | 360-374-2288
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Fax | 360-374-2283
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Provider Business Mailing Address
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Address Line | PO BOX 1429
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City | FORKS
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State | WA
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Zip | 98331-1429
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Country | US
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Telephone | 360-374-2288
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Fax | 360-374-2283
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | KYLE TIMOTHY FUKANO
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Credential | DDS
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Telephone | 360-374-2288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DE00008801
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License Number State | WA
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