Healthcare Provider Details

I. General information

NPI: 1396022604
Provider Name (Legal Business Name): JONATHAN MARTIN KIRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E 5TH ST SUITE 300
FLINT MI
48502-1641
US

IV. Provider business mailing address

G3375 S SAGINAW ST
BURTON MI
48529-1277
US

V. Phone/Fax

Practice location:
  • Phone: 810-406-4246
  • Fax: 810-424-6029
Mailing address:
  • Phone: 810-743-6830
  • Fax: 810-743-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902015775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: