Healthcare Provider Details

I. General information

NPI: 1467627919
Provider Name (Legal Business Name): KIMBERLY A. KEMPISTY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 GOAT SPRINGS ROAD
TAOS NM
87571-1946
US

IV. Provider business mailing address

P.O. BOX 1946 1090 GOAT SPRINGS ROAD
TAOS NM
87571-1946
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4224
  • Fax: 575-751-5210
Mailing address:
  • Phone: 575-758-4224
  • Fax: 575-751-5210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902010086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: