Provider Demographics
NPI:1104948124
Name:YOUNG, KIRK HICKS (MS, DDS)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:HICKS
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 BELLAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4516
Mailing Address - Country:US
Mailing Address - Phone:904-269-6011
Mailing Address - Fax:904-215-0236
Practice Address - Street 1:1850 BELLAIR BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4516
Practice Address - Country:US
Practice Address - Phone:904-269-6011
Practice Address - Fax:904-215-0236
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 90251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics