Provider Demographics
NPI:1790851707
Name:DOTY, RAYMOND KIMBLE JR (DDS, MS)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:KIMBLE
Last Name:DOTY
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:R
Other - Middle Name:KIMBLE
Other - Last Name:DOTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:1119 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2664
Mailing Address - Country:US
Mailing Address - Phone:228-864-8521
Mailing Address - Fax:228-863-8992
Practice Address - Street 1:1119 42ND AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2664
Practice Address - Country:US
Practice Address - Phone:228-864-8521
Practice Address - Fax:228-863-8992
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660144Medicaid