Healthcare Provider Details

I. General information

NPI: 1972773281
Provider Name (Legal Business Name): JOHN NORMAN KIMMICH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 S MAIN ST
DUPO IL
62239-1347
US

IV. Provider business mailing address

195 S MAIN ST
DUPO IL
62239-1347
US

V. Phone/Fax

Practice location:
  • Phone: 618-286-4400
  • Fax: 618-286-4407
Mailing address:
  • Phone: 618-286-4400
  • Fax: 618-286-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number013590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: