MEDICARE: DR. ERIC LEE KIMBALL D.D.S.

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	7999	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41948	OTHER		WELLMARK BCBS PROVIDER #
2	640-03389	OTHER	AL	BCBS OF ALABAMA
3	7999IA 002	OTHER	IA	DELTA DENTAL OF IOWA
4	742541	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1639180920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC LEE KIMBALL D.D.S.

Provider Business Mailing Address
First Line	:	301 SHERIDAN RD
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-4023
Country	:	US
Telephone Number	:	319-232-8386
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 E SAN MARNAN DR
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50702-5837
Country	:	US
Telephone Number	:	319-235-6287
Fax Number	:	319-235-6740

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/08/2007

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