Provider Demographics
NPI:1366670937
Name:MORAN, KIMBERLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MORAN
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 1:3236 E CHANDLER BLVD
Mailing Address - Street 2:#1085
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7207
Mailing Address - Country:US
Mailing Address - Phone:248-202-8438
Mailing Address - Fax:
Practice Address - Street 1:1911 W MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6929
Practice Address - Country:US
Practice Address - Phone:480-838-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH6385124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist