Provider Demographics
NPI:1952743429
Name:BATES, KIMBERLY ROBERTS (DMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROBERTS
Last Name:BATES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JEAN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1303 W LEXINGTON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-3100
Mailing Address - Country:US
Mailing Address - Phone:859-745-4455
Mailing Address - Fax:859-745-4466
Practice Address - Street 1:1303 W LEXINGTON AVE
Practice Address - Street 2:STE A
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-3100
Practice Address - Country:US
Practice Address - Phone:859-745-4455
Practice Address - Fax:859-745-4466
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8267 GD122300000X
KY9358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100332580Medicaid