Provider Demographics
NPI:1659546687
Name:ELLENDER, KIRK GERARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:GERARD
Last Name:ELLENDER
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 1:2110 I 10 SERVICE RD
Mailing Address - Street 2:SUITE #201
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-443-3337
Mailing Address - Fax:504-443-3337
Practice Address - Street 1:2110 I 10 SERVICE RD
Practice Address - Street 2:SUITE #201
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065
Practice Address - Country:US
Practice Address - Phone:504-443-3337
Practice Address - Fax:504-443-3337
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist