Provider Demographics
NPI:1598013401
Name:PHELPS, KIMBERLY (DMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 BROADSTONE LOOP
Mailing Address - Street 2:APT 103
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-2456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12813 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2803
Practice Address - Country:US
Practice Address - Phone:813-962-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist