Healthcare Provider Details

I. General information

NPI: 1043766603
Provider Name (Legal Business Name): KIMBERLY CORPUS R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 04/02/2022
Certification Date: 04/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 DECATUR ST SE
ATLANTA GA
30312-1848
US

IV. Provider business mailing address

33 11TH ST NE UNIT 1105
ATLANTA GA
30309-4649
US

V. Phone/Fax

Practice location:
  • Phone: 404-843-8600
  • Fax:
Mailing address:
  • Phone: 727-735-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH17953
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH010304
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: