Provider Demographics
NPI:1083992689
Name:GRATZ, KIRSTINA JESSICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRSTINA
Middle Name:JESSICA
Last Name:GRATZ
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 1:13618 RANIER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8640
Mailing Address - Country:US
Mailing Address - Phone:641-208-7953
Mailing Address - Fax:
Practice Address - Street 1:21781 OMEGA CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7809
Practice Address - Country:US
Practice Address - Phone:319-430-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-30
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08858122300000X
IN12013407A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist