Provider Demographics
NPI:1518043330
Name:KIMMEL, JEFFREY WOLF (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WOLF
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 IRENE LANE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3934
Mailing Address - Country:US
Mailing Address - Phone:631-499-0099
Mailing Address - Fax:631-858-1753
Practice Address - Street 1:102 IRENE LANE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3934
Practice Address - Country:US
Practice Address - Phone:631-499-0099
Practice Address - Fax:631-858-1753
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21755OtherDDS