Provider Demographics
NPI:1316965742
Name:MUMFORD-CLARKE, KYMBERLI A (DDS)
Entity type:Individual
Prefix:
First Name:KYMBERLI
Middle Name:A
Last Name:MUMFORD-CLARKE
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:KYMBERLI
Other - Middle Name:A
Other - Last Name:MUMFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2804 SAINT JOHNS BLUFF RD S STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3778
Mailing Address - Country:US
Mailing Address - Phone:904-493-1005
Mailing Address - Fax:904-345-2961
Practice Address - Street 1:2804 SAINT JOHNS BLUFF RD S STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3778
Practice Address - Country:US
Practice Address - Phone:904-493-1005
Practice Address - Fax:904-345-2961
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00158481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075583400Medicaid