Healthcare Provider Details

I. General information

NPI: 1972656130
Provider Name (Legal Business Name): KIRK L. JENKINS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 12TH AVE RD
NAMPA ID
83686-5047
US

IV. Provider business mailing address

109 12TH AVE RD
NAMPA ID
83686-5047
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-6161
  • Fax: 208-466-3607
Mailing address:
  • Phone: 208-466-6161
  • Fax: 208-466-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1898
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: