Provider Demographics
NPI:1083758015
Name:HAAS, KIMBERLY SUZANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUZANNE
Last Name:HAAS
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 1:630 POINT SAN PEDRO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2514
Mailing Address - Country:US
Mailing Address - Phone:415-453-9470
Mailing Address - Fax:
Practice Address - Street 1:630 POINT SAN PEDRO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2514
Practice Address - Country:US
Practice Address - Phone:415-453-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist