Provider Demographics
NPI:1083039234
Name:LEAL, KIMBERLI
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:
Last Name:LEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 W 83RD ST
Mailing Address - Street 2:APT R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 GRAND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4700
Practice Address - Country:US
Practice Address - Phone:646-908-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026194001223P0221X
NY0587451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry