Provider Demographics
NPI:1114088556
Name:DERRICK, KRISTIN ROWLAND (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:ROWLAND
Last Name:DERRICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:ADAIR
Other - Last Name:ROWLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-0837
Mailing Address - Country:US
Mailing Address - Phone:864-833-5400
Mailing Address - Fax:
Practice Address - Street 1:1208 SPRINGDALE DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7225
Practice Address - Country:US
Practice Address - Phone:864-833-5400
Practice Address - Fax:864-833-5417
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice