| NPI | 1750883963 |
|---|---|
| Former Name | KYLE EDWARD HERNDON |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11057) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2018-03-03 |
| Last Update Date | 2021-12-09 |