Provider Demographics
NPI:1215925177
Name:PINKHAM, JIMMIE L JR (DDS)
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:L
Last Name:PINKHAM
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-5641
Mailing Address - Country:US
Mailing Address - Phone:712-328-0708
Mailing Address - Fax:712-328-8991
Practice Address - Street 1:3549 11TH AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-5641
Practice Address - Country:US
Practice Address - Phone:712-328-0708
Practice Address - Fax:712-328-8991
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA76231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077917240OtherNE MEDICAID
IA0094250Medicaid