Kyle Douglass Poulsen, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

64955 Issued in CA

Practice address

29121 Newport Rd Ste 101
Menifee, CA 92584-5121

Phone

(951) 228-9296

NPI assigned

Sep 1, 2015

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441065600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1718841600000",
    "number": "1982071379",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29121 NEWPORT RD STE 101",
            "city": "MENIFEE",
            "state": "CA",
            "postal_code": "925845121",
            "telephone_number": "951-228-9296"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29121 NEWPORT RD STE 101",
            "city": "MENIFEE",
            "state": "CA",
            "postal_code": "925845121",
            "telephone_number": "951-228-9296"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "32891 Western Hills Dr Ste 103",
            "address_purpose": "LOCATION",
            "city": "winchester",
            "state": "CA",
            "postal_code": "92596",
            "country_code": "US",
            "telephone_number": "951-335-5169",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "POULSEN",
        "first_name": "KYLE",
        "middle_name": "DOUGLASS",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-09-01",
        "last_updated": "2024-06-20",
        "certification_date": "2024-06-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "64955",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alyce Popiel
• Elisha Porter
• Amber Portman, LVN
• Portsmouth Senior Home LLC
• Poulsen Dental Corporation
• Pourshirazi Dental Corporation
• Homayoun Pourshirazi, D.M.D.
• Andrea Powell
• Jeremy Taylor Powers, DMD
• Radha Prasad

• General Practice Dentistry in Menifee, CA
• Providers in Menifee, CA by specialty
• General Practice Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.