Provider Demographics
NPI:1447725809
Name:DEXTER, KYLE RAYMOND KWON (PHD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:RAYMOND KWON
Last Name:DEXTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 DRIVEWAY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-2806
Mailing Address - Country:US
Mailing Address - Phone:603-834-5929
Mailing Address - Fax:
Practice Address - Street 1:122 1ST AVE STE 400
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4871
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK164185103TA0400X, 103T00000X
NY022959103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical