Provider Demographics
NPI:1417486481
Name:KIMBALL ENDODONTICS
Entity Type:Organization
Organization Name:KIMBALL ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-232-3750
Mailing Address - Street 1:5603 WEEPING WAY
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-6398
Mailing Address - Country:US
Mailing Address - Phone:415-595-1957
Mailing Address - Fax:
Practice Address - Street 1:1331 E PROSPECT RD UNIT B1
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1367
Practice Address - Country:US
Practice Address - Phone:970-232-3750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO202034261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental