Provider Demographics
NPI:1780945279
Name:MCCRACKEN, KELLY LEIGH (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEIGH
Last Name:MCCRACKEN
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 1:8915 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-1645
Mailing Address - Country:US
Mailing Address - Phone:816-916-0516
Mailing Address - Fax:
Practice Address - Street 1:8915 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1645
Practice Address - Country:US
Practice Address - Phone:816-916-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist