Provider Demographics
NPI:1497731574
Name:HERBST, KELLIE C (RDH)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:C
Last Name:HERBST
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:C
Other - Last Name:GUARDADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1416 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:402 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3407
Practice Address - Country:US
Practice Address - Phone:660-665-2741
Practice Address - Fax:660-665-3109
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003847124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist