Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 12121 | NC |
NPI | 1003406752 |
---|---|
Provider Name | Kyle Denton |
First Address | La Grange, NC 28551-0008 |
Second Address | La Grange, NC 28551-2005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2021 |
Last Update Date | 26/01/2021 |