Provider Demographics
NPI:1255640553
Name:CHURCH, KIPP OWENS (DMD)
Entity type:Individual
Prefix:DR
First Name:KIPP
Middle Name:OWENS
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4632
Mailing Address - Country:US
Mailing Address - Phone:928-782-4392
Mailing Address - Fax:928-782-2089
Practice Address - Street 1:550 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4632
Practice Address - Country:US
Practice Address - Phone:928-782-4392
Practice Address - Fax:928-782-2089
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD8103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist