Provider Demographics
NPI:1598801995
Name:REDICK, KIMBERLY GAIL (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:GAIL
Last Name:REDICK
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 1:131 SILVERWOOD COMMERCIAL DR SUITE #400
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5131
Mailing Address - Country:US
Mailing Address - Phone:912-826-1905
Mailing Address - Fax:912-826-1171
Practice Address - Street 1:131 SILVERWOOD COMMERCIAL DR SUITE #400
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5131
Practice Address - Country:US
Practice Address - Phone:912-826-1905
Practice Address - Fax:912-826-1171
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1819395OtherUNITED CONCORDIA