Provider Demographics
NPI:1487664348
Name:CHASTAIN, KIMBERLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:CHASTAIN
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 1:14 NORTHEAST COVE CIR
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534
Mailing Address - Country:US
Mailing Address - Phone:706-216-8036
Mailing Address - Fax:
Practice Address - Street 1:655 ATLANTA RD
Practice Address - Street 2:STE 701
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2785
Practice Address - Country:US
Practice Address - Phone:770-889-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0117961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice