Provider Demographics
NPI:1861819559
Name:KIRK, MICHAEL DIETRICH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DIETRICH
Last Name:KIRK
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 1:80 ANNANDALE RD APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-3682
Mailing Address - Country:US
Mailing Address - Phone:219-508-9075
Mailing Address - Fax:
Practice Address - Street 1:1173 WHIPPLE ST
Practice Address - Street 2:NHCNE NEWPORT DENTAL CLINIC
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02841-1632
Practice Address - Country:US
Practice Address - Phone:401-841-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0111121223G0001X
VA04014141741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice