Provider Demographics
NPI:1053608752
Name:KLOOSTER, KYLE (MD, DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KLOOSTER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 E JEFFERSON AVE
Mailing Address - Street 2:SUITE 70
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3730
Mailing Address - Country:US
Mailing Address - Phone:313-499-4775
Mailing Address - Fax:313-499-4953
Practice Address - Street 1:7633 E JEFFERSON AVE
Practice Address - Street 2:SUITE 70
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3730
Practice Address - Country:US
Practice Address - Phone:313-499-4775
Practice Address - Fax:313-499-4953
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010204431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery