Healthcare Provider Details

I. General information

NPI: 1932180023
Provider Name (Legal Business Name): KIMBROUGH DENTAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 S KIMBROUGH AVE
SPRINGFIELD MO
65807-5011
US

IV. Provider business mailing address

3111 S KIMBROUGH AVE
SPRINGFIELD MO
65807-5011
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-5661
  • Fax: 417-889-6814
Mailing address:
  • Phone: 417-887-5661
  • Fax: 417-889-6814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SUSAN J PEROTKA
Title or Position: DOCTOR CO OWNER
Credential: DMD
Phone: 417-887-5661