Provider Demographics
NPI:1649481086
Name:DAVIS, KIRK JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:JAY
Last Name:DAVIS
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 1:15615 W DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2046
Mailing Address - Country:US
Mailing Address - Phone:402-614-9378
Mailing Address - Fax:402-502-4960
Practice Address - Street 1:15615 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2046
Practice Address - Country:US
Practice Address - Phone:402-614-9378
Practice Address - Fax:402-502-4960
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE46821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice