Provider Demographics
NPI:1154463818
Name:CHILDRESS, KURT R (DMD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:R
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 HWY 899
Mailing Address - Street 2:
Mailing Address - City:HINDMAN
Mailing Address - State:KY
Mailing Address - Zip Code:41822
Mailing Address - Country:US
Mailing Address - Phone:606-785-3164
Mailing Address - Fax:606-785-0107
Practice Address - Street 1:566 HIGHWAY 899
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-0849
Practice Address - Country:US
Practice Address - Phone:606-785-3164
Practice Address - Fax:606-785-0107
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60066297Medicaid