MEDICARE: DR. KYLE STEWART WENDFELDT DDS, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	58394	CA

General Provider Information

NPI Number	:	1558346981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE STEWART WENDFELDT DDS, MS

Provider Business Mailing Address
First Line	:	2401 GREEN RIVER DR
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-2202
Country	:	US
Telephone Number	:	619-600-7137
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 GREEN RIVER DR
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-2202
Country	:	US
Telephone Number	:	619-600-7137
Fax Number	:

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

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	10/15/2012

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