1700348653 NPI number — JUSTIN JAMES KIRKWOOD DMD

Table of content: JUSTIN JAMES KIRKWOOD DMD (NPI 1700348653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700348653 NPI number — JUSTIN JAMES KIRKWOOD DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRKWOOD
Provider First Name:
JUSTIN
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700348653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 ALBERT SABIN WAY, ML 0461
Provider Second Line Business Mailing Address:
HOLMES HOSPITAL, OFFICE 2220
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-584-2586
Provider Business Mailing Address Fax Number:
513-584-1125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GREAT OAKS BLVD STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12203-7924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
186-826-4005
Provider Business Practice Location Address Fax Number:
518-682-6402
Provider Enumeration Date:
04/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 064184 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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