Provider Demographics
NPI:1275780330
Name:HENDRICKS, KRISTEN CAMPBELL (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:CAMPBELL
Last Name:HENDRICKS
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 1:1912 W PECAN ST
Mailing Address - Street 2:SUITE A103
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3561
Mailing Address - Country:US
Mailing Address - Phone:512-989-3200
Mailing Address - Fax:512-989-3201
Practice Address - Street 1:1912 W PECAN ST
Practice Address - Street 2:SUITE A103
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-3561
Practice Address - Country:US
Practice Address - Phone:512-989-3200
Practice Address - Fax:512-989-3201
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194293010Medicaid