Provider Demographics
NPI:1083407290
Name:ANDERSON, KYLE JAMES
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16109 PENN CENTRAL WAY
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-6120
Mailing Address - Country:US
Mailing Address - Phone:719-646-9665
Mailing Address - Fax:
Practice Address - Street 1:5430 TUTT BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2515
Practice Address - Country:US
Practice Address - Phone:719-380-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002063321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice