Provider Demographics
NPI:1033874896
Name:BLACK, KRISTIN LEE (RDH, OMT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:L
Other - Last Name:CRAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:5520 UNION SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-9223
Mailing Address - Country:US
Mailing Address - Phone:937-546-8594
Mailing Address - Fax:
Practice Address - Street 1:9001 N MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1175
Practice Address - Country:US
Practice Address - Phone:937-836-7282
Practice Address - Fax:937-836-7394
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31.007966124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist