MEDICARE: DR. DEREK G KIRKHAM DDS

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	1223P0221X	Pediatric Dentistry	8149	CO

General Provider Information

NPI Number	:	1952458184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK G KIRKHAM DDS

Provider Business Mailing Address
First Line	:	10155 PINE GLADE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-2401
Country	:	US
Telephone Number	:	719-332-1396
Fax Number	:	719-272-6399

Provider Business Practice Location Address
First Line	:	9480 BRIAR VILLAGE POINT
Second Line	:	SUITE 301
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920
Country	:	US
Telephone Number	:	719-522-0123
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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