Provider Demographics
NPI:1184762338
Name:HERICKS, KEVIN B (DDS PC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:HERICKS
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:415 16TH AVE CIR NE
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-886-2222
Mailing Address - Fax:605-884-0674
Practice Address - Street 1:415 16TH AVE CIR NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-886-2222
Practice Address - Fax:605-884-0074
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM880122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist