Provider Demographics
NPI:1407850761
Name:WIRTH, KURTIS E (DDS)
Entity Type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:E
Last Name:WIRTH
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 1:1107 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4212
Mailing Address - Country:US
Mailing Address - Phone:815-965-5233
Mailing Address - Fax:815-965-9311
Practice Address - Street 1:1107 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4212
Practice Address - Country:US
Practice Address - Phone:815-965-5233
Practice Address - Fax:815-965-9311
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19016003122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19016003Medicaid
WI0017598Medicaid
IL19016003Medicaid