Provider Demographics
NPI:1841817657
Name:LEE, KIMBERLY NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:MOREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 SILVERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-1801
Mailing Address - Country:US
Mailing Address - Phone:601-248-3757
Mailing Address - Fax:
Practice Address - Street 1:105 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6651
Practice Address - Country:US
Practice Address - Phone:601-856-5227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4127-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice