Provider Demographics
NPI:1205948239
Name:BULLARD-DEMAIO, KRISTIE CAROL (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:CAROL
Last Name:BULLARD-DEMAIO
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 1:800 IRVING AVENUE
Mailing Address - Street 2:SYRAVCUSE VAMC-DENTAL SERVICE (160)
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-425-4400
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:SYRACUSE VAMC-DENTAL SERVICE (160)
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044441-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice