Provider Demographics
NPI:1417039967
Name:KIMBALL, LELAND BLANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LELAND
Middle Name:BLANE
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 NEBRASKA AVE
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-0388
Mailing Address - Fax:573-596-0410
Practice Address - Street 1:1724 NEBRASKA AVE
Practice Address - Street 2:USA DENTAC
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-0388
Practice Address - Fax:573-596-0410
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550111223E0200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice