Provider Demographics
NPI:1972773281
Name:KIMMICH, JOHN NORMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NORMAN
Last Name:KIMMICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUPO
Mailing Address - State:IL
Mailing Address - Zip Code:62239-1347
Mailing Address - Country:US
Mailing Address - Phone:618-286-4400
Mailing Address - Fax:618-286-4407
Practice Address - Street 1:195 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DUPO
Practice Address - State:IL
Practice Address - Zip Code:62239-1347
Practice Address - Country:US
Practice Address - Phone:618-286-4400
Practice Address - Fax:618-286-4407
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013590122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist