Provider Demographics
NPI:1578858403
Name:STEWART, BRADLEY KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KYLE
Last Name:STEWART
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DECATUR PIKE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-2513
Mailing Address - Country:US
Mailing Address - Phone:423-745-6465
Mailing Address - Fax:
Practice Address - Street 1:501 DECATUR PIKE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-2513
Practice Address - Country:US
Practice Address - Phone:423-745-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN93071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice