Provider Demographics
NPI:1417133026
Name:TINERVIN, KRISTEN HEATHER
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:HEATHER
Last Name:TINERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STEPHENS AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6659
Mailing Address - Country:US
Mailing Address - Phone:406-829-8900
Mailing Address - Fax:
Practice Address - Street 1:2100 STEPHENS AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6659
Practice Address - Country:US
Practice Address - Phone:406-829-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT26122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist