Provider Demographics
NPI:1346800356
Name:KIST, MALLORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:KIST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4050
Mailing Address - Country:US
Mailing Address - Phone:814-860-1251
Mailing Address - Fax:
Practice Address - Street 1:366 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2702
Practice Address - Country:US
Practice Address - Phone:814-860-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0422491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice