Provider Demographics
NPI:1679019244
Name:QUINONES, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:QUINONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CHARLES TOWN RD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-9667
Mailing Address - Country:US
Mailing Address - Phone:803-563-2299
Mailing Address - Fax:
Practice Address - Street 1:1395 CHARLES TOWN RD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-9667
Practice Address - Country:US
Practice Address - Phone:803-563-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC122300000X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1781330930Medicaid
SC6782213576Medicaid