Provider Demographics
NPI:1508457326
Name:JEFFREY G. KIMBLE DDS
Entity Type:Organization
Organization Name:JEFFREY G. KIMBLE DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-257-1759
Mailing Address - Street 1:211 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1715
Mailing Address - Country:US
Mailing Address - Phone:304-257-1759
Mailing Address - Fax:
Practice Address - Street 1:211 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1715
Practice Address - Country:US
Practice Address - Phone:304-257-1759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7800023000Medicaid