Healthcare Provider Details

I. General information

NPI: 1649327164
Provider Name (Legal Business Name): KIMBERLY BLAIR SMITH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 MAIN ST N
MENDENHALL MS
39114-3318
US

IV. Provider business mailing address

238 JAMES BERRY RD
MAGEE MS
39111-5248
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-1223
  • Fax: 601-847-9131
Mailing address:
  • Phone: 601-849-9569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3186-01
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: