Provider Demographics
NPI:1679744239
Name:JONATHAN N. KRISTIANTO, DDS INC.
Entity Type:Organization
Organization Name:JONATHAN N. KRISTIANTO, DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISTIANTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-444-0882
Mailing Address - Street 1:1556 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-5101
Mailing Address - Country:US
Mailing Address - Phone:831-444-0882
Mailing Address - Fax:
Practice Address - Street 1:1556 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-5101
Practice Address - Country:US
Practice Address - Phone:831-444-0882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA374411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB37441-01OtherDENTI-CAL