Provider Demographics
NPI:1073841797
Name:SELF, KIMBERLY R (DDS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:SELF
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 1:1296 AGVIK STREET
Mailing Address - Street 2:PO BOX 29
Mailing Address - City:BARROW
Mailing Address - State:AK
Mailing Address - Zip Code:99723-0029
Mailing Address - Country:US
Mailing Address - Phone:907-852-9221
Mailing Address - Fax:907-852-9297
Practice Address - Street 1:1296 AGVIK STREET
Practice Address - Street 2:
Practice Address - City:BARROW
Practice Address - State:AK
Practice Address - Zip Code:99723-0029
Practice Address - Country:US
Practice Address - Phone:907-852-9221
Practice Address - Fax:907-852-9297
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24630122300000X
AK1395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist