Provider Demographics
NPI:1447350988
Name:PODVIA, KRISTAN DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:DAVID
Last Name:PODVIA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 NEW BERLIN ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226
Mailing Address - Country:US
Mailing Address - Phone:904-765-5573
Mailing Address - Fax:904-765-5515
Practice Address - Street 1:3118 NEW BERLIN ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226
Practice Address - Country:US
Practice Address - Phone:904-765-5573
Practice Address - Fax:904-765-5515
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN145571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice