Provider Demographics
NPI:1073063236
Name:PIETILA, KRISTA LYNN
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:PIETILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 CAMPUS DR
Mailing Address - Street 2:STE B
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1644
Mailing Address - Country:US
Mailing Address - Phone:906-483-1445
Mailing Address - Fax:906-483-1122
Practice Address - Street 1:56901 S 6TH ST
Practice Address - Street 2:STE 1 & 2
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-2946
Practice Address - Country:US
Practice Address - Phone:906-483-1177
Practice Address - Fax:906-483-1188
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist