MEDICARE: KYLE COUNTRYMAN 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	1223E0200X	Endodontics	34996	TX

General Provider Information

NPI Number	:	1437633054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE COUNTRYMAN DDS

Provider Business Mailing Address
First Line	:	2003 NW 57TH ST UNIT 304
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-5538
Country	:	US
Telephone Number	:	903-340-7943
Fax Number	:

Provider Business Practice Location Address
First Line	:	4421 LONG PRAIRIE RD STE 400
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-1752
Country	:	US
Telephone Number	:	972-691-3636
Fax Number	:

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

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	10/01/2019

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