Provider Demographics
NPI:1447698394
Name:KENSON, DALLAS DANIELLE (DDS)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:DANIELLE
Last Name:KENSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80828
Mailing Address - Country:US
Mailing Address - Phone:719-775-2367
Mailing Address - Fax:719-775-2365
Practice Address - Street 1:820 1ST STREET
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828
Practice Address - Country:US
Practice Address - Phone:719-775-2367
Practice Address - Fax:719-775-2365
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL#