1063716678 NPI number — MRS. KIMBERLEY BROOKE MOWERY DMD

Table of content: MRS. KIMBERLEY BROOKE MOWERY DMD (NPI 1063716678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063716678 NPI number — MRS. KIMBERLEY BROOKE MOWERY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOWERY
Provider First Name:
KIMBERLEY
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063716678
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4960 NEWBERRY ROAD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-332-6725
Provider Business Mailing Address Fax Number:
352-372-1717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4960 NEWBERRY ROAD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-332-6725
Provider Business Practice Location Address Fax Number:
352-332-6725
Provider Enumeration Date:
12/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN15902 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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