Healthcare Provider Details

I. General information

NPI: 1619096625
Provider Name (Legal Business Name): JONATHAN LOUIS KIRKLAND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

IV. Provider business mailing address

211 PUBLIC RD
RAYNE LA
70578-7610
US

V. Phone/Fax

Practice location:
  • Phone: 337-706-3415
  • Fax:
Mailing address:
  • Phone: 985-510-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3776
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: