Provider Demographics
NPI:1811022189
Name:CHILDRESS, FRANK BURTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRANK
Middle Name:BURTON
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:FRANK
Other - Middle Name:B
Other - Last Name:CHILDRESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2530 GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-542-0525
Mailing Address - Fax:
Practice Address - Street 1:1407 W 29TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-639-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78075769Medicaid