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General NPI Number Information
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NPI Number | 1922892223
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Entity Type | Organization
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Legal Business Name | THE EVOLVE GROUP HOLDINGS, LLC
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Dates
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Enumeration Date | 04/09/2025
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Last Update Date | 04/09/2025
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Provider Practice Location Address
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Address Line | 20136 MACK AVE
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City | GROSSE POINTE WOODS
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State | MI
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Zip | 48236-1820
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Country | US
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Telephone | 309-532-2059
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Fax |
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Provider Business Mailing Address
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Address Line | 15766 GLASTONBURY AVE
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City | DETROIT
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State | MI
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Zip | 48223-1318
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Country | US
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Telephone | 309-532-2059
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Fax |
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Authorized Official
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Title or Position | CO-FOUNDER
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Name | KYLE KINGSTON
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Credential |
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Telephone | 309-532-2059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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