Provider Demographics
NPI:1124403894
Name:WHITEHEAD, KACEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KACEY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19121 W LAKE HOUSTON PKWY
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-4825
Mailing Address - Country:US
Mailing Address - Phone:281-446-2153
Mailing Address - Fax:
Practice Address - Street 1:19121 W LAKE HOUSTON PKWY
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-4825
Practice Address - Country:US
Practice Address - Phone:281-446-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice