Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DE00005584 | WA |
NPI | 1003977893 |
---|---|
Provider Name | John Dexter Kimball III |
First Address | Spokane, WA 99223-4800 |
Second Address | Spokane, WA 99223-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DE00005584 | DENTAL LICENSE # (01) | WA |