Provider Demographics
NPI:1639395957
Name:CERTA, KIMBERLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:CERTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 MAIN ST
Mailing Address - Street 2:#308
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2507
Mailing Address - Country:US
Mailing Address - Phone:703-328-5904
Mailing Address - Fax:
Practice Address - Street 1:12739 DIRECTORS LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2461
Practice Address - Country:US
Practice Address - Phone:703-494-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA66991223G0001X
CA554681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice