Provider Demographics
NPI:1285618413
Name:KIMMES, NICOLE SUZETTE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:SUZETTE
Last Name:KIMMES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2693
Mailing Address - Country:US
Mailing Address - Phone:207-221-4739
Mailing Address - Fax:207-523-1915
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-221-4739
Practice Address - Fax:207-523-1915
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN44811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47071268413Medicaid
NE7997OtherBCBS PROVIDER ID