Provider Demographics
NPI:1609229103
Name:BERRONG, KYLE NATHANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:NATHANIEL
Last Name:BERRONG
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 1:1413 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-7702
Mailing Address - Country:US
Mailing Address - Phone:865-773-9285
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE OMFS CLINIC BLDG 9, 2ND DECK RM 2505
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-6122
Practice Address - Country:US
Practice Address - Phone:301-295-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10250122300000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No122300000XDental ProvidersDentist