Provider Demographics
NPI:1336839430
Name:CHARLES, KRISTA CAMILLE (RDH)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:CAMILLE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 TERRELL DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-5144
Mailing Address - Country:US
Mailing Address - Phone:318-564-8187
Mailing Address - Fax:
Practice Address - Street 1:3510 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-9567
Practice Address - Country:US
Practice Address - Phone:346-815-9997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25340124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist