Provider Demographics
NPI:1538396999
Name:WILSON, KYLE A (DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 LAKOTA TRL STE 200
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-3601
Mailing Address - Country:US
Mailing Address - Phone:469-907-1080
Mailing Address - Fax:
Practice Address - Street 1:3575 LAKOTA TRL STE 200
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-3601
Practice Address - Country:US
Practice Address - Phone:469-907-1080
Practice Address - Fax:972-542-6691
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009013997122300000X
WADE 605149231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist