Provider Demographics
NPI:1982947107
Name:DONALDSON, KRISTIN LEE
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:DONALDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2944 CHAMBERLAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3476
Mailing Address - Country:US
Mailing Address - Phone:330-875-0775
Mailing Address - Fax:
Practice Address - Street 1:1951 STATE ROUTE 59 STE B
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-8128
Practice Address - Country:US
Practice Address - Phone:330-678-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30024165122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program