Provider Demographics
NPI:1992995690
Name:ROURK, KEVIN JUDE (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JUDE
Last Name:ROURK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-5903
Mailing Address - Country:US
Mailing Address - Phone:419-351-5583
Mailing Address - Fax:
Practice Address - Street 1:1200 S DETROIT AVE
Practice Address - Street 2:TOLEDO VA CBOC
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-5903
Practice Address - Country:US
Practice Address - Phone:419-351-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-28
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice