Provider Demographics
NPI:1407385735
Name:AUSTIN, KRYSTIN BOURDUA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRYSTIN
Middle Name:BOURDUA
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KRYSTIN
Other - Middle Name:
Other - Last Name:BOURDUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3997 BECKLEY RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-7660
Mailing Address - Country:US
Mailing Address - Phone:304-431-5499
Mailing Address - Fax:304-431-2661
Practice Address - Street 1:3997 BECKLEY RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-7660
Practice Address - Country:US
Practice Address - Phone:304-425-4585
Practice Address - Fax:304-431-3400
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1407385735Medicaid