Provider Demographics
NPI:1164084919
Name:POWELL, KRISTEN M
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:POWELL
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 1:1101 N ANN ARBOR ST
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-2000
Mailing Address - Country:US
Mailing Address - Phone:734-429-2522
Mailing Address - Fax:734-429-7055
Practice Address - Street 1:1101 N ANN ARBOR ST
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-2000
Practice Address - Country:US
Practice Address - Phone:734-429-2522
Practice Address - Fax:734-429-7055
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist