Healthcare Provider Details

I. General information

NPI: 1194828657
Provider Name (Legal Business Name): KIRK E HOUSTON DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12313 GREENVILLE HIGHWAY
LYMAN SC
29365
US

IV. Provider business mailing address

12313 GREENVILLE HIGHWAY
LYMAN SC
29365
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-3322
  • Fax: 864-949-3953
Mailing address:
  • Phone: 864-439-3322
  • Fax: 864-949-3953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number03598
License Number StateSC

VIII. Authorized Official

Name: DR. KIRK EDWARD HOUSTON
Title or Position: CEO
Credential: DMD
Phone: 864-439-3322