Provider Demographics
NPI:1831376029
Name:HOUSTON, KIRK EDWARD (DMD PA)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:EDWARD
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12313 GREENVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-1515
Mailing Address - Country:US
Mailing Address - Phone:864-439-3322
Mailing Address - Fax:864-949-3953
Practice Address - Street 1:12313 GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1515
Practice Address - Country:US
Practice Address - Phone:864-439-3322
Practice Address - Fax:864-949-3953
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9592Medicaid
SCZX3598Medicaid
SCZX3598Medicaid