Healthcare Provider Details

I. General information

NPI: 1801872395
Provider Name (Legal Business Name): KIMBERLY A EBNER DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 E GREEN STREET SUITE 105
PASADENA CA
91106
US

IV. Provider business mailing address

1060 E GREEN STREET SUITE 105
PASADENA CA
91106
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-9246
  • Fax: 626-564-8395
Mailing address:
  • Phone: 626-796-9246
  • Fax: 626-564-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD37328
License Number StateCA

VIII. Authorized Official

Name: DR. KIMBERLY ANN EBNER
Title or Position: OWNER
Credential: DDS
Phone: 626-796-9246