Provider Demographics
NPI:1912923475
Name:CHILDRESS, KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CHILDRESS
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 1:721 MECHEM DR
Mailing Address - Street 2:SIERRA MALL #5
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6911
Mailing Address - Country:US
Mailing Address - Phone:575-257-0246
Mailing Address - Fax:575-257-0249
Practice Address - Street 1:721 MECHEM DR
Practice Address - Street 2:SIERRA MALL #5
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6911
Practice Address - Country:US
Practice Address - Phone:575-257-0246
Practice Address - Fax:575-257-0249
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81641223G0001X
NM27041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88284751Medicaid