Healthcare Provider Details

I. General information

NPI: 1801294947
Provider Name (Legal Business Name): KIMBERLEY VALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 HARTFORD AVE
JOHNSTON RI
02919-7109
US

IV. Provider business mailing address

484 WEEDEN ST
PAWTUCKET RI
02860-1740
US

V. Phone/Fax

Practice location:
  • Phone: 401-519-1940
  • Fax: 401-351-6613
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH02437
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH88324
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: