Healthcare Provider Details

I. General information

NPI: 1982913935
Provider Name (Legal Business Name): KENNETH W CHILDRESS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MECHEM DR SIERRA MALL #5
RUIDOSO NM
88345-6911
US

IV. Provider business mailing address

721 MECHEM DR SIERRA MALL #5
RUIDOSO NM
88345-6911
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-0246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2704
License Number StateNM

VIII. Authorized Official

Name: KENNETH CHILDRESS
Title or Position: PRESIDENT
Credential: DDS
Phone: 719-671-7369