Provider Demographics
NPI:1578621645
Name:KIMBLE, JEFFREY G (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:G
Last Name:KIMBLE
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 1:211 VIRGINIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847
Mailing Address - Country:US
Mailing Address - Phone:304-257-1759
Mailing Address - Fax:304-257-1759
Practice Address - Street 1:211 VIRGINIA AVENUE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:304-257-1759
Practice Address - Fax:304-257-1759
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV34301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7800023000Medicaid