Provider Demographics
NPI:1760112700
Name:NWANKWO, KYLE KENECHUKWU
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:KENECHUKWU
Last Name:NWANKWO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KENECHUKWU
Other - Middle Name:K
Other - Last Name:NWANKWO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:447 SOUTH SHORE RD
Mailing Address - Street 2:
Mailing Address - City:MARMORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08223-2603
Mailing Address - Country:US
Mailing Address - Phone:862-300-7244
Mailing Address - Fax:
Practice Address - Street 1:447 SOUTH SHORE RD
Practice Address - Street 2:
Practice Address - City:MARMORA
Practice Address - State:NJ
Practice Address - Zip Code:08223-8202
Practice Address - Country:US
Practice Address - Phone:718-590-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI029687001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid