Provider Demographics
NPI:1043386782
Name:KIMBLE, LISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 CRESTMARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2665
Mailing Address - Country:US
Mailing Address - Phone:678-945-0034
Mailing Address - Fax:770-892-4779
Practice Address - Street 1:870 CRESTMARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2665
Practice Address - Country:US
Practice Address - Phone:678-945-0034
Practice Address - Fax:770-892-4779
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO123131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice