Provider Demographics
NPI:1609503036
Name:KRISTIN MAIN DDS, PLLC
Entity Type:Organization
Organization Name:KRISTIN MAIN DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-403-1510
Mailing Address - Street 1:110 VILLAGE RD NE UNIT A
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-7412
Mailing Address - Country:US
Mailing Address - Phone:910-371-0966
Mailing Address - Fax:910-371-0968
Practice Address - Street 1:110 VILLAGE RD NE UNIT A
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7412
Practice Address - Country:US
Practice Address - Phone:910-371-0966
Practice Address - Fax:910-371-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1609005859Medicaid