Provider Demographics
NPI:1164876280
Name:KIRK, KYLE CLAYTON (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:CLAYTON
Last Name:KIRK
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 SIR BARTON WAY # 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2275
Mailing Address - Country:US
Mailing Address - Phone:859-543-2456
Mailing Address - Fax:
Practice Address - Street 1:4420 106TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-4700
Practice Address - Country:US
Practice Address - Phone:253-417-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60647135390200000X
KY101531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty