Healthcare Provider Details

I. General information

NPI: 1891000154
Provider Name (Legal Business Name): KENNETH C DYER IV D.D.S., M.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 BRAINERD RD SUITE 3
CHATTANOOGA TN
37411-3835
US

IV. Provider business mailing address

4610 BRAINERD RD SUITE 3
CHATTANOOGA TN
37411-3835
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-6525
  • Fax: 423-629-9889
Mailing address:
  • Phone: 423-624-6525
  • Fax: 423-629-9889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS9149
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: