Healthcare Provider Details

I. General information

NPI: 1891530663
Provider Name (Legal Business Name): NOAH BRAYTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7973 STRIKE BLVD
FORT CAMPBELL KY
42223-5529
US

IV. Provider business mailing address

2192 FAIRFAX DR
CLARKSVILLE TN
37043-1940
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-6027
  • Fax:
Mailing address:
  • Phone: 616-745-4336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602171
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: