Provider Demographics
NPI:1427054071
Name:GREENWELL, KIMBERLY (DMD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:KERR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:709 MOBJACK PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1929
Mailing Address - Country:US
Mailing Address - Phone:757-873-3001
Mailing Address - Fax:
Practice Address - Street 1:709 MOBJACK PL
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1929
Practice Address - Country:US
Practice Address - Phone:757-873-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014112891223G0001X
KY79381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003209Medicaid
KY9178015OtherDORAL DENTAL