Provider Demographics
NPI:1487146361
Name:CAUDELL, ETHAN KYLE (DMD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:KYLE
Last Name:CAUDELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 WHITEVILLE RD NW
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4507
Mailing Address - Country:US
Mailing Address - Phone:910-754-6718
Mailing Address - Fax:
Practice Address - Street 1:343 WHITEVILLE RD NW
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4507
Practice Address - Country:US
Practice Address - Phone:910-754-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist