Provider Demographics
NPI:1508883240
Name:MIX, KRISTIN L (DMD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:MIX
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 1:290 BAKER AVE
Mailing Address - Street 2:SOUTH 102
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:978-369-4808
Mailing Address - Fax:978-369-2341
Practice Address - Street 1:290 BAKER AVE
Practice Address - Street 2:SOUTH 102
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:978-369-4808
Practice Address - Fax:978-369-2341
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice