Provider Demographics
NPI:1730118829
Name:DETTORI, KIMBERLY A (DDS, MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:DETTORI
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 SE OCEAN BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2475
Mailing Address - Country:US
Mailing Address - Phone:772-221-3700
Mailing Address - Fax:772-221-9107
Practice Address - Street 1:903 SE OCEAN BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2475
Practice Address - Country:US
Practice Address - Phone:772-221-3700
Practice Address - Fax:772-221-9107
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN121431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics