Provider Demographics
NPI:1407234248
Name:JENNIFER CRISS, DDS,PA
Entity Type:Organization
Organization Name:JENNIFER CRISS, DDS,PA
Other - Org Name:NACOGDOCHES PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNFIER
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-559-7200
Mailing Address - Street 1:1602 E STARR AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4312
Mailing Address - Country:US
Mailing Address - Phone:936-559-7200
Mailing Address - Fax:
Practice Address - Street 1:1602 E STARR AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4312
Practice Address - Country:US
Practice Address - Phone:936-559-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214171223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16283102Medicaid