Healthcare Provider Details

I. General information

NPI: 1346356490
Provider Name (Legal Business Name): JAMES RICHARD KIMMELMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BYHALIA RD
HERNANDO MS
38632-1319
US

IV. Provider business mailing address

4488 WESTMINISTER CIR
SOUTHAVEN MS
38671-8594
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5239
  • Fax: 662-449-0758
Mailing address:
  • Phone: 662-449-3654
  • Fax: 662-449-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberPER-277-95
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: