Provider Demographics
NPI:1922636927
Name:KRISKA, PAULINA M
Entity Type:Individual
Prefix:
First Name:PAULINA
Middle Name:M
Last Name:KRISKA
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 1:771 REEVES MILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5979
Mailing Address - Country:US
Mailing Address - Phone:336-755-0946
Mailing Address - Fax:
Practice Address - Street 1:CMC DENTAL CLINIC
Practice Address - Street 2:1000 BLYTHE BLVD
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-355-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC435135241122300000X
NC32814206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist