Provider Demographics
NPI:1689130858
Name:CLARKE, KRYSTLE MARIA (DDS)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:MARIA
Last Name:CLARKE
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 1:250 KENNEDY ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5227
Mailing Address - Country:US
Mailing Address - Phone:202-726-5250
Mailing Address - Fax:202-726-1288
Practice Address - Street 1:250 KENNEDY ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5227
Practice Address - Country:US
Practice Address - Phone:202-726-5250
Practice Address - Fax:202-726-1288
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10019311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice