Provider Demographics
NPI:1073583324
Name:KIRK, JERRY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:J
Last Name:KIRK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25147 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127
Mailing Address - Country:US
Mailing Address - Phone:313-277-3000
Mailing Address - Fax:313-277-3068
Practice Address - Street 1:25147 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2198
Practice Address - Country:US
Practice Address - Phone:313-277-3000
Practice Address - Fax:313-277-3068
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010119091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice