Provider Demographics
NPI:1679691349
Name:TINER, KIRK ELLIOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:ELLIOTT
Last Name:TINER
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 1:9184 E STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9510
Mailing Address - Country:US
Mailing Address - Phone:916-686-1101
Mailing Address - Fax:916-714-3195
Practice Address - Street 1:9184 E STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9510
Practice Address - Country:US
Practice Address - Phone:916-686-1101
Practice Address - Fax:916-714-3195
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG94015-01OtherDENTI-CAL
CA20-4753840OtherTAX I.D. #