Provider Demographics
NPI:1083369789
Name:KIMBALL, AMANDA E (RDH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-3153
Mailing Address - Country:US
Mailing Address - Phone:757-748-5961
Mailing Address - Fax:
Practice Address - Street 1:1087 N MILITARY HWY
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-0028
Practice Address - Country:US
Practice Address - Phone:757-451-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402205456124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist