Provider Demographics
NPI:1740265131
Name:GORENCHAN, KRISTA CAROL-ISON (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:CAROL-ISON
Last Name:GORENCHAN
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 1:421 26TH ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-2322
Mailing Address - Country:US
Mailing Address - Phone:906-428-2319
Mailing Address - Fax:
Practice Address - Street 1:N16088 BALSAM LANE
Practice Address - Street 2:
Practice Address - City:SPAULDING
Practice Address - State:MI
Practice Address - Zip Code:49886
Practice Address - Country:US
Practice Address - Phone:906-497-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice