MEDICARE: DR. KYNE ARLEN HOMERSTAD D.D.S.

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	1223G0001X	General Practice Dentistry	29027	TX

General Provider Information

NPI Number	:	1760820500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYNE ARLEN HOMERSTAD D.D.S.

Provider Business Mailing Address
First Line	:	2521 SOUTHMORE AVE
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-1451
Country	:	US
Telephone Number	:	713-477-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	2521 SOUTHMORE AVE
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-1451
Country	:	US
Telephone Number	:	713-477-1414
Fax Number	:

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

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	07/08/2014

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