1346693892 NPI number — KYLE BLAIR

Table of content: (NPI 1346693892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346693892 NPI number — KYLE BLAIR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KYLE BLAIR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COVINGTON FAMILY DENTAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346693892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17121 SE 270TH PL STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98042-5431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-630-5500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17121 SE 270TH PL STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98042-5431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-630-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BLAIR
Authorized Official First Name:
KLYE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
253-630-5500

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DE60170682 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1245546068 . This is a "NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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