Provider Demographics
NPI:1396435004
Name:BELCHER, KIMBERLY MICHELLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:BELCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KS
Mailing Address - Zip Code:67017-0063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:660-626-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00000001223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice