Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DD3267 | NM |
NPI | 1023320165 |
---|---|
Provider Name | Dr. Kristin Wayne Hendricks |
First Address | Santa Fe, NM 87505-6305 |
Second Address | Santa Fe, NM 87505-6305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2010 |
Last Update Date | 06/07/2010 |