MEDICARE: DR. KIM DEWAYNE KEMMERLY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7322	NV

General Provider Information

NPI Number	:	1356979603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM DEWAYNE KEMMERLY DMD

Provider Business Mailing Address
First Line	:	5905 W CHARLESTON BLVD APT 250
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1375
Country	:	US
Telephone Number	:	318-332-6347
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 W CHARLESTON BLVD APT 250
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1375
Country	:	US
Telephone Number	:	318-332-6347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2020
Last Update Date	:	03/31/2020

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