Provider Demographics
NPI:1558968024
Name:KIRTLEY, CONNOR MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:MICHAEL
Last Name:KIRTLEY
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 1:325 N WALNUT ST STE A
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2113
Mailing Address - Country:US
Mailing Address - Phone:812-522-1899
Mailing Address - Fax:812-522-2759
Practice Address - Street 1:325 N WALNUT ST STE A
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2113
Practice Address - Country:US
Practice Address - Phone:812-522-1899
Practice Address - Fax:812-522-2759
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013495A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice