Provider Demographics
NPI:1063820884
Name:KRIST, CARRIE M (RDH)
Entity Type:Individual
Prefix:MISS
First Name:CARRIE
Middle Name:M
Last Name:KRIST
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W BELTLINE HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4226
Mailing Address - Country:US
Mailing Address - Phone:608-443-5500
Mailing Address - Fax:608-441-2385
Practice Address - Street 1:3434 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4155
Practice Address - Country:US
Practice Address - Phone:608-443-5482
Practice Address - Fax:608-443-5570
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002504-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist