Provider Demographics
NPI:1174053243
Name:MALDONADO, KYLE MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MICHAEL
Last Name:MALDONADO
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 1:808 C M FAGAN DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-6049
Mailing Address - Country:US
Mailing Address - Phone:985-542-8719
Mailing Address - Fax:
Practice Address - Street 1:808 C M FAGAN DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-542-8719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty