Provider Demographics
NPI:1376604298
Name:CARBAJAL, KIM IRENE (RDH)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:IRENE
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:IRENE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13706 W BELL RD
Mailing Address - Street 2:STE 2
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-584-9910
Mailing Address - Fax:623-584-9940
Practice Address - Street 1:13706 W BELL RD
Practice Address - Street 2:STE 2
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374
Practice Address - Country:US
Practice Address - Phone:623-584-9910
Practice Address - Fax:623-584-9940
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4251124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist