Provider Demographics
NPI:1609005859
Name:MAIN, KRISTIN LEIGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LEIGH
Last Name:MAIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8470 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-977-0627
Mailing Address - Fax:919-977-4079
Practice Address - Street 1:1625 N. MAIN ST.
Practice Address - Street 2:SUITE 201
Practice Address - City:FUQUAY-VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526
Practice Address - Country:US
Practice Address - Phone:919-557-7799
Practice Address - Fax:919-557-6677
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC88931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program