Provider Demographics
NPI:1306374467
Name:MERRITT, KIMBERLY KAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAY
Last Name:MERRITT
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 1:281 N SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7363
Mailing Address - Country:US
Mailing Address - Phone:405-315-7759
Mailing Address - Fax:
Practice Address - Street 1:1226 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DRUMRIGHT
Practice Address - State:OK
Practice Address - Zip Code:74030-5826
Practice Address - Country:US
Practice Address - Phone:918-844-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200112080AMedicaid