Provider Demographics
NPI:1922112143
Name:KIRK, KEVIN LUCAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LUCAS
Last Name:KIRK
Suffix:
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 1:3742 RUSTIC LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4235
Mailing Address - Country:US
Mailing Address - Phone:904-739-8978
Mailing Address - Fax:
Practice Address - Street 1:3965 CONFEDERATE POINT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-5401
Practice Address - Country:US
Practice Address - Phone:904-772-0508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice