Provider Demographics
NPI:1114094927
Name:KIRK, MARK ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
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 1:308 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986
Mailing Address - Country:US
Mailing Address - Phone:304-536-1721
Mailing Address - Fax:304-536-1561
Practice Address - Street 1:308 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986
Practice Address - Country:US
Practice Address - Phone:304-536-1721
Practice Address - Fax:304-536-1561
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3137WV1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133809000Medicaid