Provider Demographics
NPI:1225416423
Name:NEALY, KIMBERLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:NEALY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MALOTKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1675 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0982
Mailing Address - Country:US
Mailing Address - Phone:208-342-3695
Mailing Address - Fax:
Practice Address - Street 1:1675 W HILL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0982
Practice Address - Country:US
Practice Address - Phone:208-342-3695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-52301223G0001X
CA637651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice