Healthcare Provider Details

I. General information

NPI: 1700348653
Provider Name (Legal Business Name): JUSTIN JAMES KIRKWOOD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GREAT OAKS BLVD STE 112
ALBANY NY
12203-7924
US

IV. Provider business mailing address

200 ALBERT SABIN WAY, ML 0461 HOLMES HOSPITAL, OFFICE 2220
CINCINNATI OH
45267
US

V. Phone/Fax

Practice location:
  • Phone: 186-826-4005
  • Fax: 518-682-6402
Mailing address:
  • Phone: 513-584-2586
  • Fax: 513-584-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number064184
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: