Provider Demographics
NPI:1003180092
Name:NALL, KRISTA WHALEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:WHALEN
Last Name:NALL
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 1:620 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-3433
Mailing Address - Country:US
Mailing Address - Phone:859-992-9317
Mailing Address - Fax:
Practice Address - Street 1:3174 MACK RD STE 5
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5369
Practice Address - Country:US
Practice Address - Phone:513-802-9713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX287911223G0001X
OH30.026248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice