Healthcare Provider Details

I. General information

NPI: 1164876280
Provider Name (Legal Business Name): KYLE CLAYTON KIRK DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 106TH ST SW
MUKILTEO WA
98275-4700
US

IV. Provider business mailing address

2517 SIR BARTON WAY # 200
LEXINGTON KY
40509-2275
US

V. Phone/Fax

Practice location:
  • Phone: 253-417-8274
  • Fax:
Mailing address:
  • Phone: 859-543-2456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10153
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDE60647135
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: