Provider Demographics
NPI:1497221055
Name:KIMBROUGH, SARAH BURNHAM
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BURNHAM
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 UNION AVE STE S301
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3513
Mailing Address - Country:US
Mailing Address - Phone:901-448-6213
Mailing Address - Fax:
Practice Address - Street 1:7117 U S HIGHWAY 98 STE 10
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1757
Practice Address - Country:US
Practice Address - Phone:601-450-4320
Practice Address - Fax:601-450-4323
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3924-17122300000X
MSOR-580-201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist