Provider Demographics
NPI:1528134392
Name:CASTILLE, KIMBERLEY M (DDS)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:M
Last Name:CASTILLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:MICHELLE
Other - Last Name:CASTILLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1670 GARTH BROOKS BLVD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099
Mailing Address - Country:US
Mailing Address - Phone:405-494-3080
Mailing Address - Fax:
Practice Address - Street 1:1670 GARTH BROOKS BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-494-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-25
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72601223G0001X
LA57521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1857521Medicaid