Provider Demographics
NPI:1326509456
Name:CARSTENS, KIMBERLY AMANDA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AMANDA
Last Name:CARSTENS
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 1:549 BROADWAY STE 102
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5012
Mailing Address - Country:US
Mailing Address - Phone:516-551-4657
Mailing Address - Fax:
Practice Address - Street 1:549 BROADWAY STE 102
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5012
Practice Address - Country:US
Practice Address - Phone:516-541-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061156-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice