Provider Demographics
NPI:1992911598
Name:INGRAM, KIMBERLY KERR (DMD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KERR
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 15068
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-5068
Mailing Address - Country:US
Mailing Address - Phone:601-583-4004
Mailing Address - Fax:601-583-4005
Practice Address - Street 1:2104 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-583-4004
Practice Address - Fax:601-583-4005
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3006-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice