Healthcare Provider Details

I. General information

NPI: 1023320165
Provider Name (Legal Business Name): KRISTIN WAYNE HENDRICKS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 S SAINT FRANCIS DR
SANTA FE NM
87505-4037
US

IV. Provider business mailing address

1439 S SAINT FRANCIS DR
SANTA FE NM
87505-4037
US

V. Phone/Fax

Practice location:
  • Phone: 505-473-5437
  • Fax: 505-438-3443
Mailing address:
  • Phone: 505-473-5437
  • Fax: 505-438-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD3267
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS109479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: