Provider Demographics
NPI:1912029174
Name:KIRBY, TIMOTHY W (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:KIRBY
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 1:3701 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-2839
Mailing Address - Country:US
Mailing Address - Phone:405-236-4755
Mailing Address - Fax:405-236-1080
Practice Address - Street 1:3701 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-2839
Practice Address - Country:US
Practice Address - Phone:405-236-4755
Practice Address - Fax:405-236-1080
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089030AMedicaid