MEDICARE: BEAVER CREEK DENTAL PLLC

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	261QD0000X	Dental Clinic/Center	10067	TN

General Provider Information

NPI Number	:	1518407766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAVER CREEK DENTAL PLLC

Provider Business Mailing Address
First Line	:	7652 OAK RIDGE HWY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37931-3335
Country	:	US
Telephone Number	:	865-896-3065
Fax Number	:

Provider Business Practice Location Address
First Line	:	7652 OAK RIDGE HWY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37931-3335
Country	:	US
Telephone Number	:	865-896-3065
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KYLE ROBERT SMITH
Credential	:	DDS
Telephone Number	:	865-256-0661

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	03/06/2017

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