Provider Demographics
NPI:1154310647
Name:GRADY, KIMBERLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CHRISTIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-539-8239
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:BLDG 4554 ATTN 59 MDW/SGHC
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice