Provider Demographics
NPI:1194828657
Name:KIRK E HOUSTON DMD PA
Entity Type:Organization
Organization Name:KIRK E HOUSTON DMD PA
Other - Org Name:FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-439-3322
Mailing Address - Street 1:12313 GREENVILLE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365
Mailing Address - Country:US
Mailing Address - Phone:864-439-3322
Mailing Address - Fax:864-949-3953
Practice Address - Street 1:12313 GREENVILLE HIGHWAY
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365
Practice Address - Country:US
Practice Address - Phone:864-439-3322
Practice Address - Fax:864-949-3953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC03598122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9592Medicaid