MEDICARE: JONATHAN MARTIN KIRT

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	124Q00000X	Dental Hygienist	2902015775	MI

General Provider Information

NPI Number	:	1396022604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN MARTIN KIRT

Provider Business Mailing Address
First Line	:	G3375 S SAGINAW ST
Second Line	:
City	:	BURTON
State	:	MI
Zip	:	48529-1277
Country	:	US
Telephone Number	:	810-743-6830
Fax Number	:	810-743-7102

Provider Business Practice Location Address
First Line	:	225 E 5TH ST
Second Line	:	SUITE 300
City	:	FLINT
State	:	MI
Zip	:	48502-1641
Country	:	US
Telephone Number	:	810-406-4246
Fax Number	:	810-424-6029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	11/15/2011

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