MEDICARE: BEAVERCREEK OH - KYLE JACKSON DDS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1184577660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAVERCREEK OH - KYLE JACKSON DDS INC

Provider Business Mailing Address
First Line	:	4090 INDIAN RIPPLE RD STE 102
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-3292
Country	:	US
Telephone Number	:	937-986-1886
Fax Number	:

Provider Business Practice Location Address
First Line	:	4090 INDIAN RIPPLE RD STE 102
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-3292
Country	:	US
Telephone Number	:	937-986-1886
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MAGGI EVANS
Credential	:
Telephone Number	:	720-603-4800

Provider Enumeration Date	:	02/16/2026
Last Update Date	:	02/16/2026

Similar Medicare Providers

1710562251 — KEEP SMILING DENTAL GROUP DRS. RODDY & PALM LLC
Practice Location Address:

4090 INDIAN RIPPLE RD STE 101
BEAVERCREEK, OH
45440-3292

Practice Phone: 937-426-5340
Practice Fax:

1013649490 — MIRANDA TATOM
Practice Location Address:

3292 BENCHWOOD RD
DAYTON, OH
45414-2704

Practice Phone: 937-668-1729
Practice Fax:

1912850595 — FALLON BRADFORD
Practice Location Address:

4120 BROOKDALE LN UNIT 1
DAYTON, OH
45440-3998

Practice Phone: 937-901-1439
Practice Fax:

1841097276 — JONNA FALKNER
Practice Location Address:

5963 KENTSHIRE DR STE A
DAYTON, OH
45440-4253

Practice Phone: 937-952-6379
Practice Fax:

1184577595 — SAMANTHA WILBURN CSFA
Practice Location Address:

3997 SAN MARINO ST
DAYTON, OH
45440-1313

Practice Phone: 740-222-4798
Practice Fax:

1396270187 — MS. KERRI K LEWIS
Practice Location Address:

130 SHELFORD WAY
DAYTON, OH
45440-3658

Practice Phone: 401-864-0032
Practice Fax:

Directions to “BEAVERCREEK OH - KYLE JACKSON DDS INC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.