Healthcare Provider Details

I. General information

NPI: 1831361013
Provider Name (Legal Business Name): RUSSELL K KIRK, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 WEST BADDOUR PARKWAY SUITE F
LEBANON TN
37087
US

IV. Provider business mailing address

1409 WEST BADDOUR PARKWAY SUITE F
LEBANON TN
37087
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: DR. RUSSELL KEITH KIRK
Title or Position: PRESIDENT
Credential: DDS
Phone: 615-453-7800