1164631057 NPI number — CREATIVE DENTAL TED H. KIMBALL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164631057 NPI number — CREATIVE DENTAL TED H. KIMBALL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE DENTAL TED H. KIMBALL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1164631057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1262 COLUSA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUBA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95991-3653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-751-1977
Provider Business Mailing Address Fax Number:
530-751-1997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1262 COLUSA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUBA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95991-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-751-1977
Provider Business Practice Location Address Fax Number:
530-751-1997
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBALL
Authorized Official First Name:
TED
Authorized Official Middle Name:
H
Authorized Official Title or Position:
DOCTOR DDS
Authorized Official Telephone Number:
530-751-1977

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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