Provider Demographics
NPI:1881690139
Name:KIRKWOOD, BRIAN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:KIRKWOOD
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 1:101 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2177
Mailing Address - Country:US
Mailing Address - Phone:317-462-3456
Mailing Address - Fax:317-462-3465
Practice Address - Street 1:101 N STATE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2177
Practice Address - Country:US
Practice Address - Phone:317-462-3456
Practice Address - Fax:317-462-3465
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN816952Medicare UPIN
IN0000000104288Medicare UPIN
IN000000090675Medicare UPIN