Provider Demographics
NPI:1235302233
Name:DANTA-DAHL, KIMBERLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:DANTA-DAHL
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 1:42550 GARFIELD RD
Mailing Address - Street 2:STE 104B
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1644
Mailing Address - Country:US
Mailing Address - Phone:586-228-2800
Mailing Address - Fax:
Practice Address - Street 1:42550 GARFIELD RD
Practice Address - Street 2:STE 104B
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1644
Practice Address - Country:US
Practice Address - Phone:586-228-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010159491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice