1710962626 NPI number — DR. KRISTA COLLEEN IRWIN DMD

Table of content: DR. KRISTA COLLEEN IRWIN DMD (NPI 1710962626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710962626 NPI number — DR. KRISTA COLLEEN IRWIN DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRWIN
Provider First Name:
KRISTA
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710962626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WARREN ST
Provider Second Line Business Mailing Address:
APT 206
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-3621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-610-6980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CAMP CASEY DC
Provider Second Line Business Practice Location Address:
618TH DC (AS) UNIT # 15658
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96224-5658
Provider Business Practice Location Address Country Code:
KR
Provider Business Practice Location Address Telephone Number:
01031356980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  21136 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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