Individual
KENNETH CHILDRESS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
721 MECHEM DR, SIERRA MALL #5, RUIDOSO, NM 88345-6911
(575) 257-0246
(575) 257-0249
Mailing address
721 MECHEM DR, SIERRA MALL #5, RUIDOSO, NM 88345-6911
(575) 257-0246
(575) 257-0249
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
2704
NM
1223G0001X
General Practice Dentistry
8164
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
88284751
—
NM
Enumeration date
07/15/2006
Last updated
04/24/2012
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