Provider Demographics
NPI:1154019628
Name:HOMECILLO, KYLEE A (DMD, MPH)
Entity type:Individual
Prefix:DR
First Name:KYLEE
Middle Name:A
Last Name:HOMECILLO
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-4126
Mailing Address - Country:US
Mailing Address - Phone:510-535-2893
Mailing Address - Fax:
Practice Address - Street 1:1926 E 19TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-4126
Practice Address - Country:US
Practice Address - Phone:510-535-3921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA108946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program