Provider Demographics
NPI:1861471880
Name:HEADRICK, BRIAN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:HEADRICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E ELIZABETH
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-0766
Mailing Address - Country:US
Mailing Address - Phone:620-855-2288
Mailing Address - Fax:
Practice Address - Street 1:120 S FOWLER
Practice Address - Street 2:
Practice Address - City:MEADE
Practice Address - State:KS
Practice Address - Zip Code:67864-0516
Practice Address - Country:US
Practice Address - Phone:620-873-2802
Practice Address - Fax:620-873-5308
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice