Provider Demographics
NPI:1811283450
Name:CRAWFORD ELLIS, KRISTEN RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:RENEE
Last Name:CRAWFORD ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:RENEE
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3365 REGENT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3126
Mailing Address - Country:US
Mailing Address - Phone:469-351-6010
Mailing Address - Fax:469-351-6009
Practice Address - Street 1:3365 REGENT BLVD STE 120
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3126
Practice Address - Country:US
Practice Address - Phone:469-351-6010
Practice Address - Fax:469-351-6009
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014031509122300000X
LA62441223G0001X
TX29356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6244OtherBOARD OF DENTISTRY LICENSE
TX29356OtherTEXAS DENTAL LICENSE
MO2014031509OtherMISSOURI DENTAL LICENSE
MO2014031509OtherMISSOURI DENTAL LICENSE