Provider Demographics
NPI:1881664076
Name:PROCKELO, KIMBERLEY K (RDH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:K
Last Name:PROCKELO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23936
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85734-3936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DM AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-6097
Practice Address - Country:US
Practice Address - Phone:520-228-2651
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH1617124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist