Provider Demographics
NPI:1144554650
Name:SMITH, KYLE (MSOM)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:17040 W. GREENFIELD AVE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6899
Mailing Address - Country:US
Mailing Address - Phone:262-439-8055
Mailing Address - Fax:262-289-9776
Practice Address - Street 1:17040 W. GREENFIELD AVE
Practice Address - Street 2:SUITE #6
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6899
Practice Address - Country:US
Practice Address - Phone:262-439-8055
Practice Address - Fax:262-289-9776
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI585-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist