Provider Demographics
NPI:1134135825
Name:VAN KIRK, KENNETH C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:VAN 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 1:1125 W KAGY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5881
Mailing Address - Country:US
Mailing Address - Phone:406-587-1688
Mailing Address - Fax:406-582-5473
Practice Address - Street 1:1125 W KAGY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5881
Practice Address - Country:US
Practice Address - Phone:406-587-1688
Practice Address - Fax:406-582-5473
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID134932OtherTRI-CARE