1639180920 NPI number — DR. ERIC LEE KIMBALL D.D.S.

Table of content: DR. ERIC LEE KIMBALL D.D.S. (NPI 1639180920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639180920 NPI number — DR. ERIC LEE KIMBALL D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBALL
Provider First Name:
ERIC
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

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:
1639180920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 SHERIDAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50701-4023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-232-8386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 E SAN MARNAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50702-5837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-235-6287
Provider Business Practice Location Address Fax Number:
319-235-6740
Provider Enumeration Date:
08/11/2006

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:  7999 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41948 . This is a "WELLMARK BCBS PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 640-03389 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 7999IA 002 . This is a "DELTA DENTAL OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 742541 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".