Provider Demographics
NPI:1669029245
Name:VAUGHT, KRISTIN MARIE (DMD)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:MARIE
Last Name:VAUGHT
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 1:1030 WILDY RD
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-9795
Mailing Address - Country:US
Mailing Address - Phone:815-830-0928
Mailing Address - Fax:
Practice Address - Street 1:595 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1046
Practice Address - Country:US
Practice Address - Phone:815-634-8009
Practice Address - Fax:815-634-2008
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190322921223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice