Provider Demographics
NPI:1366979288
Name:SCHNACKENBERG, KYLE J (DMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:SCHNACKENBERG
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 1:3404 SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-5665
Mailing Address - Country:US
Mailing Address - Phone:850-934-2720
Mailing Address - Fax:850-934-2717
Practice Address - Street 1:3404 SANTA ROSA DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-5665
Practice Address - Country:US
Practice Address - Phone:850-934-2720
Practice Address - Fax:850-934-2717
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN226111223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice