Provider Demographics
NPI:1114331865
Name:MIYAMOTO, KIMBERLY (DDS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MIYAMOTO
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 1:2530 S PARKER RD
Mailing Address - Street 2:#201
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1623
Mailing Address - Country:US
Mailing Address - Phone:303-750-2460
Mailing Address - Fax:
Practice Address - Street 1:2530 S PARKER RD
Practice Address - Street 2:#201
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1623
Practice Address - Country:US
Practice Address - Phone:303-750-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63400122300000X
CO002026581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist