MEDICARE: SMILE REVIVAL LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1982561718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE REVIVAL LLC

Provider Business Mailing Address
First Line	:	105 SPRUCE ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40507-2109
Country	:	US
Telephone Number	:	859-810-8320
Fax Number	:

Provider Business Practice Location Address
First Line	:	178 MINI MALL DR
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-1170
Country	:	US
Telephone Number	:	859-231-0596
Fax Number	:

Authorized Official
Title or Position	:	SOLE MANAGER
Name	:	ANDREW WHITE
Credential	:
Telephone Number	:	859-810-8320

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	04/07/2026

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