Provider Demographics
NPI:1669778601
Name:KIRK D. SATROM, DDS MS PC
Entity type:Organization
Organization Name:KIRK D. SATROM, DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SATROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:618-624-0800
Mailing Address - Street 1:741 W STATE ST
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1971
Mailing Address - Country:US
Mailing Address - Phone:618-624-0800
Mailing Address - Fax:618-624-0053
Practice Address - Street 1:741 W STATE ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1971
Practice Address - Country:US
Practice Address - Phone:618-624-0800
Practice Address - Fax:618-624-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.0095541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty