Provider Demographics
NPI:1639180920
Name:KIMBALL, ERIC LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:KIMBALL
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 1:301 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4023
Mailing Address - Country:US
Mailing Address - Phone:319-232-8386
Mailing Address - Fax:
Practice Address - Street 1:315 E SAN MARNAN DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5837
Practice Address - Country:US
Practice Address - Phone:319-235-6287
Practice Address - Fax:319-235-6740
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA79991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
41948OtherWELLMARK BCBS PROVIDER #
AL640-03389OtherBCBS OF ALABAMA
IA7999IA 002OtherDELTA DENTAL OF IOWA
742541OtherUNITED CONCORDIA