Provider Demographics
NPI:1548699341
Name:KYLE W. WHEELER, DDS, PC
Entity type:Organization
Organization Name:KYLE W. WHEELER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:434-385-6398
Mailing Address - Street 1:1084 THOMAS JEFFERSON RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2298
Mailing Address - Country:US
Mailing Address - Phone:434-385-6398
Mailing Address - Fax:434-385-6847
Practice Address - Street 1:1084 THOMAS JEFFERSON RD
Practice Address - Street 2:SUITE 5
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2298
Practice Address - Country:US
Practice Address - Phone:434-385-6398
Practice Address - Fax:434-385-6847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005293261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7813562Medicaid