Provider Demographics
NPI:1316911696
Name:HENRICHS, KELLY S (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:HENRICHS
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 1:100 W ROSS BLVD
Mailing Address - Street 2:BUILDING 2 SUITE C
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-7216
Mailing Address - Country:US
Mailing Address - Phone:620-225-6555
Mailing Address - Fax:620-225-3058
Practice Address - Street 1:100 W ROSS BLVD
Practice Address - Street 2:BUILDING 2 SUITE C
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7216
Practice Address - Country:US
Practice Address - Phone:620-225-6555
Practice Address - Fax:620-225-3058
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS008753OtherBLUE CROSS BLUE SHIELD
KS6207OtherDELTA DENTAL
KS882377OtherUNITED CONCORDIA
KS008753OtherBLUE CROSS BLUE SHIELD