Healthcare Provider Details

I. General information

NPI: 1639117468
Provider Name (Legal Business Name): W FRANK KIMBROUGH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD AD 1501
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

1459 LANEY WALKER BLVD AD 1501
AUGUSTA GA
30912-0002
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0502
  • Fax: 706-721-0502
Mailing address:
  • Phone: 706-721-0502
  • Fax: 706-721-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDNF000230
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: