Healthcare Provider Details

I. General information

NPI: 1609229103
Provider Name (Legal Business Name): KYLE NATHANIEL BERRONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE OMFS CLINIC BLDG 9, 2ND DECK RM 2505
BETHESDA MD
20889-6122
US

IV. Provider business mailing address

1413 LINCOLNSHIRE DR
MARYVILLE TN
37803-7702
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4340
  • Fax:
Mailing address:
  • Phone: 865-773-9285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10250
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number10250
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: