Provider Demographics
NPI:1972624880
Name:JEPSEN, KYLE D (DMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:D
Last Name:JEPSEN
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 1:13525 SPRUCEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-3630
Mailing Address - Country:US
Mailing Address - Phone:214-629-6153
Mailing Address - Fax:
Practice Address - Street 1:208 N MARKET ST
Practice Address - Street 2:322
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-3206
Practice Address - Country:US
Practice Address - Phone:214-757-4500
Practice Address - Fax:214-757-4501
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22833122300000X, 1223G0001X
NC135691223G0001X
CODEN.002058601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1479404-04Medicaid
TX1479404-06Medicaid
TX1804783-05Medicaid
TX1479404-01Medicaid
TX1479404-03Medicaid
TX1479404-09Medicaid
TX1479404-11Medicaid
TX1804783-02Medicaid
TX1479404-07Medicaid
TX1479404-10Medicaid
TX1479404-12Medicaid
TX1804783-03Medicaid
TX1804783-04Medicaid
TX1804783-06Medicaid
TX1479404-08Medicaid
TX1804783-07Medicaid
TX1479404-05Medicaid
TX1804783-01Medicaid