Provider Demographics
NPI:1477623007
Name:WALLER-BROWN, KIMBERLY KAY (DDS)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:KAY
Last Name:WALLER-BROWN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3803
Mailing Address - Country:US
Mailing Address - Phone:304-327-5506
Mailing Address - Fax:304-327-5506
Practice Address - Street 1:1609 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3803
Practice Address - Country:US
Practice Address - Phone:304-327-5506
Practice Address - Fax:304-324-8703
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000311Medicaid