Provider Demographics
NPI:1619688959
Name:KIRK, HEATHER CHELSEY BROOKE (RDH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CHELSEY BROOKE
Last Name:KIRK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 PRIMROSE TRL
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2644
Mailing Address - Country:US
Mailing Address - Phone:912-659-1164
Mailing Address - Fax:
Practice Address - Street 1:2120 N MAYS ST STE 430
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2108
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18960124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist