Provider Demographics
NPI:1073730107
Name:WIMBERLY, MICHAEL KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:WIMBERLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 FAIRGROVE CHURCH RD SE
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-9090
Mailing Address - Country:US
Mailing Address - Phone:828-466-2488
Mailing Address - Fax:828-466-2450
Practice Address - Street 1:1183 FAIRGROVE CHURCH RD SE
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-9090
Practice Address - Country:US
Practice Address - Phone:828-466-2488
Practice Address - Fax:828-466-2450
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990014Medicaid