Provider Demographics
NPI:1558959007
Name:MCREYNOLDS, CRYSTALIN RAY (D161066205)
Entity Type:Individual
Prefix:MISS
First Name:CRYSTALIN
Middle Name:RAY
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:D161066205
Other - Prefix:MISS
Other - First Name:CRISSI
Other - Middle Name:RAY
Other - Last Name:MCREYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5100 W CLEARWATER AVE APT H201
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 W CLEARWATER AVE APT H201
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2095
Practice Address - Country:US
Practice Address - Phone:509-820-1947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAIJR971204865OtherBLUE CROSS