Provider Demographics
NPI:1700348653
Name:KIRKWOOD, JUSTIN JAMES (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JAMES
Last Name:KIRKWOOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ALBERT SABIN WAY, ML 0461
Mailing Address - Street 2:HOLMES HOSPITAL, OFFICE 2220
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267
Mailing Address - Country:US
Mailing Address - Phone:513-584-2586
Mailing Address - Fax:513-584-1125
Practice Address - Street 1:100 GREAT OAKS BLVD STE 112
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-7924
Practice Address - Country:US
Practice Address - Phone:186-826-4005
Practice Address - Fax:518-682-6402
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0641841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program