=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164526596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS MICHAEL KIRKDORFER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2795 KIMMEL ST
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49127-0237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-7474
-----------------------------------------------------
Fax | 269-429-7565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 237 2795 KIMMEL ST
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49127-0237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-7474
-----------------------------------------------------
Fax | 269-429-7565
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901011583
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------