Healthcare Provider Details

I. General information

NPI: 1497731574
Provider Name (Legal Business Name): KELLIE C HERBST RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE C GUARDADO

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W JEFFERSON ST
KIRKSVILLE MO
63501-3407
US

IV. Provider business mailing address

1416 CROWN DR
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-2741
  • Fax: 660-665-3109
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number003847
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: