Provider Demographics
NPI:1962016253
Name:DECOURSIN, KRISTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:
Last Name:DECOURSIN
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 1:10301 BURNET RD APT 2128
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-4594
Mailing Address - Country:US
Mailing Address - Phone:920-450-4463
Mailing Address - Fax:
Practice Address - Street 1:3305 NORTHLAND DR STE 515
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4991
Practice Address - Country:US
Practice Address - Phone:512-452-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist