Provider Demographics
NPI:1811120538
Name:DIMOVA, KRISTINA (OD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:DIMOVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 BEACH ST.
Mailing Address - Street 2:BUILDING B UNIT 4
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2718
Mailing Address - Country:US
Mailing Address - Phone:401-596-2292
Mailing Address - Fax:401-596-4910
Practice Address - Street 1:85 BEACH ST.
Practice Address - Street 2:BUILDING B UNIT 4
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2718
Practice Address - Country:US
Practice Address - Phone:401-596-2292
Practice Address - Fax:401-596-4910
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICODTG00623152W00000X
RIODTG00623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1811120538OtherALL OTHER PAYERS