Provider Demographics
NPI:1457403156
Name:KIRK JR, WALTER CHARLES (DMD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:CHARLES
Last Name:KIRK JR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BREEZEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8901
Mailing Address - Country:US
Mailing Address - Phone:919-778-8469
Mailing Address - Fax:
Practice Address - Street 1:1213 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2616
Practice Address - Country:US
Practice Address - Phone:919-552-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67451223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990142Medicaid