Provider Demographics
NPI:1669011805
Name:HUMERICKHOUSE, KIMBRA W (RDH)
Entity Type:Individual
Prefix:
First Name:KIMBRA
Middle Name:W
Last Name:HUMERICKHOUSE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38066-3884
Mailing Address - Country:US
Mailing Address - Phone:901-262-4129
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE # C517
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3513
Practice Address - Country:US
Practice Address - Phone:901-448-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2695124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist