Provider Demographics
NPI:1538132865
Name:CHRISTINE L DEARTH DDS INC
Entity Type:Organization
Organization Name:CHRISTINE L DEARTH DDS INC
Other - Org Name:KINGWOOD FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LAVONNE
Authorized Official - Last Name:DEARTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-329-3142
Mailing Address - Street 1:430 MORGANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-329-3142
Mailing Address - Fax:304-329-0700
Practice Address - Street 1:430 MORGANTOWN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-329-3142
Practice Address - Fax:304-329-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4040010000Medicaid
WV104022OtherUNITED CONCORDIA