Provider Demographics
NPI:1679561716
Name:KIDBY, DONNA (DDS)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:KIDBY
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 1:2108 CALLE DE SEBASTIAN
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7314
Mailing Address - Country:US
Mailing Address - Phone:505-983-4461
Mailing Address - Fax:
Practice Address - Street 1:1442 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4031
Practice Address - Country:US
Practice Address - Phone:505-988-2178
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2274122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY89029313Medicaid