Provider Demographics
NPI:1063859791
Name:BULTEMA, KRISTY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:LYNN
Last Name:BULTEMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:FULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-292-2751
Mailing Address - Fax:
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-292-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30023921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist