Provider Demographics
NPI:1043451560
Name:FANN, KRISTINA DOISY (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:DOISY
Last Name:FANN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:DOISY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3111 ROCK BROOK FALLS LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6138
Mailing Address - Country:US
Mailing Address - Phone:832-425-7956
Mailing Address - Fax:
Practice Address - Street 1:304 W BAY AREA BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4156
Practice Address - Country:US
Practice Address - Phone:832-932-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24266122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist