=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982071379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE DOUGLASS POULSEN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29121 NEWPORT RD STE 101
-----------------------------------------------------
City | MENIFEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92584-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-228-9296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29121 NEWPORT RD STE 101
-----------------------------------------------------
City | MENIFEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92584-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-228-9296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 64955
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------