Basic Information
Provider Information | |||||||||
NPI: | 1386637353 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORNSBY | ||||||||
FirstName: | KIMBROUGH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 MEADOW VIEW BLVD | ||||||||
Address2: |   | ||||||||
City: | SUFFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 234353495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7576736263 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 E LITTLE CREEK RD | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235052603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579626769 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 07/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401411379 | VA | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.