Provider Demographics
NPI:1124440417
Name:JEFF VAN KIRK, DMD, PC
Entity type:Organization
Organization Name:JEFF VAN KIRK, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:VAN KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:216-394-3140
Mailing Address - Street 1:1390 ALPINE LAKES ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-6976
Mailing Address - Country:US
Mailing Address - Phone:216-394-3140
Mailing Address - Fax:
Practice Address - Street 1:450 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1837
Practice Address - Country:US
Practice Address - Phone:503-769-6351
Practice Address - Fax:503-759-7029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD98481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty