Provider Demographics
NPI:1104016344
Name:DONNELLY, KRISTINE (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DONNELLY
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 1:125 SW MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1650
Mailing Address - Country:US
Mailing Address - Phone:210-922-3483
Mailing Address - Fax:210-927-4975
Practice Address - Street 1:2510 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2329
Practice Address - Country:US
Practice Address - Phone:979-704-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX252391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209944216Medicaid
TX379870403Medicaid