Provider Demographics
NPI:1427828722
Name:GLOVER, KIMBERLY ANN (RDH)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GLOVER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58086 HIGHWAY 204
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:OR
Mailing Address - Zip Code:97886-6156
Mailing Address - Country:US
Mailing Address - Phone:541-709-3562
Mailing Address - Fax:
Practice Address - Street 1:508 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1315
Practice Address - Country:US
Practice Address - Phone:541-938-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3816124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist