Provider Demographics
NPI:1629645387
Name:NEWELL, KIMBERLY A (RDH, PHDH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:NEWELL
Suffix:
Gender:F
Credentials:RDH, PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 ASHBY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3216
Mailing Address - Country:US
Mailing Address - Phone:217-549-0712
Mailing Address - Fax:
Practice Address - Street 1:502 SHAW AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2352
Practice Address - Country:US
Practice Address - Phone:217-466-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020015390124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist