Provider Demographics
NPI:1326654120
Name:DISMORE, KRISTEN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DISMORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HAZELWOOD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1405
Mailing Address - Country:US
Mailing Address - Phone:631-445-1147
Mailing Address - Fax:
Practice Address - Street 1:625 BELLE TERRE RD STE 202
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2318
Practice Address - Country:US
Practice Address - Phone:631-686-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025086208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery