Provider Demographics
NPI:1598778904
Name:HENLEY-BROWN, KIMBERLY MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:HENLEY-BROWN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:HENLEY-MCCARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:904-542-7781
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-270-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA906690OtherPROVIDER # FOR TRICARE
GA00861484AMedicaid