Provider Demographics
NPI:1104928738
Name:HANSFORD, KIMBERLY S (DMD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:S
Last Name:HANSFORD
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 1:130 EVERGREEN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDDLETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1489
Mailing Address - Country:US
Mailing Address - Phone:502-410-1710
Mailing Address - Fax:502-245-5021
Practice Address - Street 1:130 EVERGREEN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDDLETOWN
Practice Address - State:KY
Practice Address - Zip Code:40243-1489
Practice Address - Country:US
Practice Address - Phone:502-410-1710
Practice Address - Fax:502-244-1244
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74691223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002474Medicaid