Provider Demographics
NPI:1982745147
Name:KIMBALL, DENTON LARMARR (OD)
Entity type:Individual
Prefix:MR
First Name:DENTON
Middle Name:LARMARR
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43965 BARLETTA ST
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3947
Mailing Address - Country:US
Mailing Address - Phone:951-302-9908
Mailing Address - Fax:
Practice Address - Street 1:1 CIVIC CENTER DR
Practice Address - Street 2:130
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2918
Practice Address - Country:US
Practice Address - Phone:760-744-2611
Practice Address - Fax:760-744-2611
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4146926OtherMEDICAL
CB205651Medicare PIN