Provider Demographics
NPI:1134511736
Name:KIMBLE, CATHERINE DAYNE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:DAYNE
Last Name:KIMBLE
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 1:216 PIEDMONT LN
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3774
Mailing Address - Country:US
Mailing Address - Phone:205-542-9361
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST
Practice Address - Street 2:BUILDING 700A
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-497-4431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9664122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist