Provider Demographics
NPI:1861524118
Name:KIRK, BLAIR ANDREW (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:ANDREW
Last Name:KIRK
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:3835 CYPRESS DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6965
Mailing Address - Country:US
Mailing Address - Phone:707-762-8047
Mailing Address - Fax:707-762-5439
Practice Address - Street 1:3835 CYPRESS DR
Practice Address - Street 2:SUITE 208
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6965
Practice Address - Country:US
Practice Address - Phone:707-762-8047
Practice Address - Fax:707-762-5439
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA403641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics