Healthcare Provider Details

I. General information

NPI: 1558322321
Provider Name (Legal Business Name): RUSSELL KEITH KIRK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 W BADDOUR PKWY SUITE #F
LEBANON TN
37087-2513
US

IV. Provider business mailing address

5594 FRANKLIN RD
LEBANON TN
37090-8101
US

V. Phone/Fax

Practice location:
  • Phone: 615-453-7800
  • Fax: 615-453-7858
Mailing address:
  • Phone: 615-453-7800
  • Fax: 615-453-7858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7103
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: