Provider Demographics
NPI:1356979603
Name:KEMMERLY, KIM DEWAYNE (DMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:DEWAYNE
Last Name:KEMMERLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 W CHARLESTON BLVD APT 250
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1375
Mailing Address - Country:US
Mailing Address - Phone:318-332-6347
Mailing Address - Fax:
Practice Address - Street 1:5905 W CHARLESTON BLVD APT 250
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1375
Practice Address - Country:US
Practice Address - Phone:318-332-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV73221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice