Provider Demographics
NPI:1811238447
Name:BETHEA, KIMANI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMANI
Middle Name:
Last Name:BETHEA
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 1:10999 RED RUN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3261
Mailing Address - Country:US
Mailing Address - Phone:410-654-4544
Mailing Address - Fax:410-654-8918
Practice Address - Street 1:10999 RED RUN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3261
Practice Address - Country:US
Practice Address - Phone:410-654-4544
Practice Address - Fax:410-654-8918
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist