Provider Demographics
NPI:1790948420
Name:BANEK, KRISTEN MARIE (OD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:BANEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2725
Mailing Address - Country:US
Mailing Address - Phone:617-782-6650
Mailing Address - Fax:617-782-2660
Practice Address - Street 1:372 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2725
Practice Address - Country:US
Practice Address - Phone:617-782-6650
Practice Address - Fax:617-782-2660
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001772152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist