Provider Demographics
NPI:1871768622
Name:KIRKSEY, CHARLES DOUGLAS (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:KIRKSEY
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 1:10611 JUDICIAL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5165
Mailing Address - Country:US
Mailing Address - Phone:703-385-0303
Mailing Address - Fax:703-385-1445
Practice Address - Street 1:10611 JUDICIAL DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5165
Practice Address - Country:US
Practice Address - Phone:703-385-0303
Practice Address - Fax:703-385-1445
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010054541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice