Provider Demographics
NPI:1699914762
Name:CHILDERS, KYLE R (DMD, MS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1382
Mailing Address - Country:US
Mailing Address - Phone:618-438-2815
Mailing Address - Fax:618-439-6127
Practice Address - Street 1:201 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1382
Practice Address - Country:US
Practice Address - Phone:618-438-2815
Practice Address - Fax:618-439-6127
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190220001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1497897284Medicare PIN