Healthcare Provider Details

I. General information

NPI: 1003160599
Provider Name (Legal Business Name): KENNETH E. BEARD, DDS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 25TH ST NW
CLEVELAND TN
37311-3892
US

IV. Provider business mailing address

415 25TH ST NW
CLEVELAND TN
37311-3892
US

V. Phone/Fax

Practice location:
  • Phone: 423-476-6541
  • Fax: 423-472-7719
Mailing address:
  • Phone: 423-476-6541
  • Fax: 423-472-7719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2223
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH E BEARD
Title or Position: PRESIDENT
Credential: DDS
Phone: 423-476-6541