Provider Demographics
NPI:1609809656
Name:WONDRA, KIRK SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:SCOTT
Last Name:WONDRA
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 1:4320 RIDGECREST DR SE STE E
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-5971
Mailing Address - Country:US
Mailing Address - Phone:505-891-1100
Mailing Address - Fax:505-891-1094
Practice Address - Street 1:4320 RIDGECREST DR SE STE E
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5971
Practice Address - Country:US
Practice Address - Phone:505-891-1100
Practice Address - Fax:505-891-1094
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM17961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM817303OtherUNITED CONCORDIA