MEDICARE: KELLEY J WIMMER

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	20463	TX

General Provider Information

NPI Number	:	1649376856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY J WIMMER

Provider Business Mailing Address
First Line	:	PO BOX 187
Second Line	:
City	:	LINDSAY
State	:	TX
Zip	:	76250-0187
Country	:	US
Telephone Number	:	940-612-4444
Fax Number	:	940-612-2142

Provider Business Practice Location Address
First Line	:	2022 W HIGHWAY 82
Second Line	:
City	:	GAINESVILLE
State	:	TX
Zip	:	76240-2051
Country	:	US
Telephone Number	:	940-612-4444
Fax Number	:	940-612-2142

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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Directions to “ KELLEY J WIMMER ” Practice Location

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