Provider Demographics
NPI:1477850873
Name:DAVIDSON, KIRK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:MICHAEL
Last Name:DAVIDSON
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 1:509 W HANLEY AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8994
Mailing Address - Country:US
Mailing Address - Phone:208-667-5447
Mailing Address - Fax:
Practice Address - Street 1:509 W HANLEY AVE
Practice Address - Street 2:STE. 201
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8994
Practice Address - Country:US
Practice Address - Phone:208-667-5447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist