Provider Demographics
NPI:1538673488
Name:GREENE, KIMBERLY SUSAN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY DEPT 100
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:6350 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877-8605
Practice Address - Country:US
Practice Address - Phone:423-587-7337
Practice Address - Fax:423-586-0614
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21825126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant