Provider Demographics
NPI:1497961338
Name:HENDERSON, KELLI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:
Last Name:HENDERSON
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 1:1425 WAKARUSA DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 WAKARUSA DR
Practice Address - Street 2:SUITE D
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3832
Practice Address - Country:US
Practice Address - Phone:405-706-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5743122300000X
KS604531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry