=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811238447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMANI BETHEA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2013
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10999 RED RUN BLVD SUITE 208
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-654-4544
-----------------------------------------------------
Fax | 410-654-8918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10999 RED RUN BLVD SUITE 208
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-654-4544
-----------------------------------------------------
Fax | 410-654-8918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12908
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------