Provider Demographics
NPI:1053784538
Name:MECHAM, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MECHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW BOND ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3798
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2357 NE CONNERS AVE STE 210
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7427
Practice Address - Country:US
Practice Address - Phone:541-389-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5094124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270364023Medicaid