Provider Demographics
NPI:1215926209
Name:KIMACK, DENISE L (DMD)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:L
Last Name:KIMACK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:L
Other - Last Name:GEWINNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10000 WATSON RD
Mailing Address - Street 2:STE D
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1854
Mailing Address - Country:US
Mailing Address - Phone:314-821-3191
Mailing Address - Fax:314-821-1304
Practice Address - Street 1:10000 WATSON RD
Practice Address - Street 2:STE D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1854
Practice Address - Country:US
Practice Address - Phone:314-821-3191
Practice Address - Fax:314-821-1304
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist