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General NPI Number Information
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NPI Number | 1982913935
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Entity Type | Organization
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Legal Business Name | KENNETH W CHILDRESS DDS PC
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Dates
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Enumeration Date | 09/24/2010
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Last Update Date | 03/14/2012
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Provider Practice Location Address
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Address Line | 721 MECHEM DR SIERRA MALL #5
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City | RUIDOSO
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State | NM
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Zip | 88345-6911
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Country | US
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Telephone | 575-257-0246
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Fax |
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Provider Business Mailing Address
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Address Line | 721 MECHEM DR SIERRA MALL #5
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City | RUIDOSO
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State | NM
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Zip | 88345-6911
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH CHILDRESS
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Credential | DDS
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Telephone | 719-671-7369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2704
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License Number State | NM
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