MEDICARE: JEFF VAN KIRK, DMD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D9848	OR

General Provider Information

NPI Number	:	1124440417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFF VAN KIRK, DMD, PC

Provider Business Mailing Address
First Line	:	1390 ALPINE LAKES ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97317-6976
Country	:	US
Telephone Number	:	216-394-3140
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 E WASHINGTON ST
Second Line	:
City	:	STAYTON
State	:	OR
Zip	:	97383-1837
Country	:	US
Telephone Number	:	503-769-6351
Fax Number	:	503-759-7029

Authorized Official
Title or Position	:	PRESIDENT, GENERAL DENTIST
Name	:	DR. JEFF SCOTT VAN KIRK
Credential	:	DMD
Telephone Number	:	216-394-3140

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	01/06/2014

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