Provider Demographics
NPI:1619912896
Name:DAVENPORT, KIRBY L (DDS)
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:L
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:K
Other - Middle Name:L
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:BULL SHOALS
Mailing Address - State:AR
Mailing Address - Zip Code:72619-0717
Mailing Address - Country:US
Mailing Address - Phone:870-445-4040
Mailing Address - Fax:870-445-3216
Practice Address - Street 1:HIGHWAY 178 & 508 HILLCREST
Practice Address - Street 2:
Practice Address - City:BULL SHOALS
Practice Address - State:AR
Practice Address - Zip Code:72619
Practice Address - Country:US
Practice Address - Phone:870-445-4040
Practice Address - Fax:870-445-3216
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR108534OtherUNITED CONCORDIA
AR58699OtherBLUE CROSS BLUE SHIELD
AR91028000040OtherQUAL CHOICE