Provider Demographics
NPI:1467976126
Name:GRADY, KIMBERLY MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MARIE
Last Name:GRADY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-2116
Mailing Address - Country:US
Mailing Address - Phone:601-479-4152
Mailing Address - Fax:
Practice Address - Street 1:2300 N HILLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2633
Practice Address - Country:US
Practice Address - Phone:601-474-3140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3960-171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice