Provider Demographics
NPI:1417110537
Name:KRYSTAL CLEAR DENTAL P.L.
Entity Type:Organization
Organization Name:KRYSTAL CLEAR DENTAL P.L.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTELLE
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:DUVERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-849-3695
Mailing Address - Street 1:18838 DUQUESNE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3421
Mailing Address - Country:US
Mailing Address - Phone:813-849-3695
Mailing Address - Fax:
Practice Address - Street 1:19445 SHUMARD OAK DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-7262
Practice Address - Country:US
Practice Address - Phone:813-849-3695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL169871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty