Provider Demographics
NPI:1821439860
Name:REILLY, KRISTIN MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:REILLY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BRUCE RD
Mailing Address - Street 2:
Mailing Address - City:GATLINBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37738-5616
Mailing Address - Country:US
Mailing Address - Phone:865-436-5024
Mailing Address - Fax:865-436-5025
Practice Address - Street 1:111 BRUCE RD
Practice Address - Street 2:
Practice Address - City:GATLINBURG
Practice Address - State:TN
Practice Address - Zip Code:37738-5616
Practice Address - Country:US
Practice Address - Phone:865-436-5024
Practice Address - Fax:865-436-5025
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2013-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN96581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice