Dental Board of California
Licensing details for: 64955
Name: POULSEN, KYLE DOUGLASS
License Type: Dentist
Primary Status: Current - Active
Method of Application: Licensure by WREB
License Relationships
AO to DDS or OMS (Owners)
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Additional Office Permit
Name: POULSEN DENTAL CORPORATION
License/Registration Type: Additional Office Permit
License Number: 79491 Primary Status: Current - Active
Address :
29121 NEWPORT RD STE 101
MENIFEE CA 92584
RIVERSIDE COUNTY
AO to DDS or OMS (Owners)
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Additional Office Permit
Name: KYLE POULSEN, DDS
License/Registration Type: Additional Office Permit
License Number: 82335 Primary Status: Current - Active
Address :
22471 Barton Road
GRAND TERRACE CA 92313
AO to DDS or OMS (Owners)
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Additional Office Permit
Name: KYLE POULSEN, DDS
License/Registration Type: Additional Office Permit
License Number: 81865 Primary Status: Current - Active
Address :
32897 WESTERN HILLS DRIVE, SUITE 102
WINCHESTER CA 92596
RIVERSIDE COUNTY
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: MENIFEE LAKES DENTAL GROUP, POULSEN DENTAL CORPORATION
License/Registration Type: Fictitious Name Permit
License Number: 13804 Primary Status: Current - Active
Address :
29121 NEWPORT RD STE 101
MENIFEE CA 92584
RIVERSIDE COUNTY
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: Grand Terrace Modern Dentistry, Dental Group of Grand Terrace Modern Dentistry, Inc.
License/Registration Type: Fictitious Name Permit
License Number: 20243 Primary Status: Current - Active
Address :
22471 Barton Rd
GRAND TERRACE CA 92313
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: THE DENTAL OFFICE OF WINCHESTER, DENTAL CORPORATION OF KYLE POULSEN
License/Registration Type: Fictitious Name Permit
License Number: 18797 Primary Status: Current - Active
Address :
32897 WESTERN HILLS DRIVE, SUITE 103
WINCHESTER CA 92596
RIVERSIDE COUNTY
