Provider Demographics
NPI:1083141154
Name:KIMBERLY, THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KIMBERLY
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 1:20 S 41ST ST APT 141
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3372
Mailing Address - Country:US
Mailing Address - Phone:330-328-2885
Mailing Address - Fax:
Practice Address - Street 1:1509 AVENUE G
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-2516
Practice Address - Country:US
Practice Address - Phone:712-325-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist