Provider Demographics
NPI:1689711699
Name:KIRK, NATHAN EARL II (DMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:EARL
Last Name:KIRK
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-0581
Mailing Address - Country:US
Mailing Address - Phone:304-201-8500
Mailing Address - Fax:304-201-8505
Practice Address - Street 1:3659 TEAYS VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9701
Practice Address - Country:US
Practice Address - Phone:304-201-8500
Practice Address - Fax:304-201-8505
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV35681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002185000Medicaid