=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639117468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | W FRANK KIMBROUGH DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1459 LANEY WALKER BLVD AD 1501
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-721-0502
-----------------------------------------------------
Fax | 706-721-0502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1459 LANEY WALKER BLVD AD 1501
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-721-0502
-----------------------------------------------------
Fax | 706-721-0502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DNF000230
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------