Healthcare Provider Details

I. General information

NPI: 1073841797
Provider Name (Legal Business Name): KIMBERLY R SELF D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 AGVIK STREET
BARROW AK
99723-0029
US

IV. Provider business mailing address

1296 AGVIK STREET PO BOX 29
BARROW AK
99723-0029
US

V. Phone/Fax

Practice location:
  • Phone: 907-852-9221
  • Fax: 907-852-9297
Mailing address:
  • Phone: 907-852-9221
  • Fax: 907-852-9297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number24630
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1395
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: