Provider Demographics
NPI:1689762494
Name:KIMBERLY PARK DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:KIMBERLY PARK DENTAL ASSOCIATES
Other - Org Name:MARC C SLIVKEN DAVID A JOHNSON THOMAS A THOL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:THUL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-359-3494
Mailing Address - Street 1:3512 JERSEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 JERSEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3332
Practice Address - Country:US
Practice Address - Phone:563-359-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA710728OtherBLUE CROSS S
IA755644OtherBLUE CROSS J
IA709842OtherBLUE CROSS T
IA0099382OtherSLIVKEN
IA0096222OtherJOHNSON
IA0096222OtherJOHNSON