Provider Demographics
NPI:1366542532
Name:DEDEN, KYLE STANLEY (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:STANLEY
Last Name:DEDEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2322
Mailing Address - Country:US
Mailing Address - Phone:207-773-4651
Mailing Address - Fax:207-773-8940
Practice Address - Street 1:611 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2322
Practice Address - Country:US
Practice Address - Phone:207-773-4651
Practice Address - Fax:207-773-8940
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06446111N00000X
MECR2084111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0463422Medicaid
IA39100OtherWELLMARK NUMBER
IA0463422Medicaid
IAV07631Medicare UPIN