Provider Demographics
NPI:1821409871
Name:DOUGLAS, KRISTEN MULLINS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MULLINS
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 E PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3527
Mailing Address - Country:US
Mailing Address - Phone:222-896-5197
Mailing Address - Fax:228-896-5192
Practice Address - Street 1:1635 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3527
Practice Address - Country:US
Practice Address - Phone:228-896-5197
Practice Address - Fax:228-896-5192
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3847-16122300000X
TN102301223P0221X
MSPEDO-534-171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04203063Medicaid