Provider Demographics
NPI:1205924131
Name:MCKISSICK, KURT ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:ALAN
Last Name:MCKISSICK
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 1:109 STOCKETT CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4565
Mailing Address - Country:US
Mailing Address - Phone:919-772-6632
Mailing Address - Fax:
Practice Address - Street 1:107 EDINBURGH SOUTH DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-8426
Practice Address - Country:US
Practice Address - Phone:919-481-3007
Practice Address - Fax:919-481-6637
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995826Medicaid