MEDICARE: DR. KYLE MARTIN FOUTZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DB-2025-0179	NM

General Provider Information

NPI Number	:	1154202158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE MARTIN FOUTZ DDS

Provider Business Mailing Address
First Line	:	2401 E 30TH ST BLDG 1
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-8939
Country	:	US
Telephone Number	:	505-327-0441
Fax Number	:	505-324-9473

Provider Business Practice Location Address
First Line	:	2401 E 30TH ST BLDG 1
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-8939
Country	:	US
Telephone Number	:	505-327-0441
Fax Number	:	505-324-9473

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2025
Last Update Date	:	09/08/2025

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