Basic Information
| Provider Information | |||||||||
| NPI: | 1639395957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CERTA | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10332 MAIN ST | ||||||||
| Address2: | #308 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220302507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033285904 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12739 DIRECTORS LOOP | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221922461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034944490 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 09/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6699 | VA | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 55468 | CA | N | Dental Providers | Dentist | General Practice |
No ID Information.