Provider Demographics
NPI:1912120023
Name:SMITH, KIMBERLY D (DDS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 US HIGHWAY 21 S
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29130-6844
Mailing Address - Country:US
Mailing Address - Phone:803-337-2920
Mailing Address - Fax:803-337-3010
Practice Address - Street 1:755 US HIGHWAY 21 S
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-6844
Practice Address - Country:US
Practice Address - Phone:803-337-2920
Practice Address - Fax:803-337-3010
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130631223G0001X
SC42911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA599440686AMedicaid
SCZX4291Medicaid