MEDICARE: DR. KURTIS E WIRTH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	19016003	IL
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19016003	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407850761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KURTIS E WIRTH DDS

Provider Business Mailing Address
First Line	:	1107 S MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-4212
Country	:	US
Telephone Number	:	815-965-5233
Fax Number	:	815-965-9311

Provider Business Practice Location Address
First Line	:	1107 S MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-4212
Country	:	US
Telephone Number	:	815-965-5233
Fax Number	:	815-965-9311

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	06/22/2016

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