Provider Demographics
NPI:1598256984
Name:KETCHEM, ERICA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:R
Last Name:KETCHEM
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 1:3568 SW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-2327
Mailing Address - Country:US
Mailing Address - Phone:816-537-6161
Mailing Address - Fax:816-537-6165
Practice Address - Street 1:3568 SW MARKET ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082
Practice Address - Country:US
Practice Address - Phone:816-537-6161
Practice Address - Fax:816-537-6165
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070191301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE