Provider Demographics
NPI:1083745681
Name:FENWICK, KRISTIN L (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:FENWICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6657 N GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6657 N GLENWOOD ST
Practice Address - Street 2:WATER'S EDGE DENTAL
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714
Practice Address - Country:US
Practice Address - Phone:208-375-0572
Practice Address - Fax:208-375-1658
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice