Provider Demographics
NPI:1639622921
Name:AFFONSO, KIMBERLIE
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:
Last Name:AFFONSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 MIL PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT LEWIS
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-966-9960
Mailing Address - Fax:
Practice Address - Street 1:9119 MIL PARK AVE.
Practice Address - Street 2:
Practice Address - City:FORT LEWIS
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant