Provider Demographics
NPI:1912028044
Name:TOLBERT, KIMBERLY W (DMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 HIGHWAY 80 W # C
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4193
Mailing Address - Country:US
Mailing Address - Phone:601-924-8833
Mailing Address - Fax:
Practice Address - Street 1:543 HIGHWAY 80 W # C
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4193
Practice Address - Country:US
Practice Address - Phone:601-924-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3071-981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660400Medicaid