Provider Demographics
NPI:1558322321
Name:KIRK, RUSSELL KEITH (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:KEITH
Last Name: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 1:5594 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-8101
Mailing Address - Country:US
Mailing Address - Phone:615-453-7800
Mailing Address - Fax:615-453-7858
Practice Address - Street 1:1409 W BADDOUR PKWY
Practice Address - Street 2:SUITE #F
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-453-7800
Practice Address - Fax:615-453-7858
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU94787Medicare UPIN