Healthcare Provider Details

I. General information

NPI: 1184171589
Provider Name (Legal Business Name): SARA KINGSTON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OFFUTT AFB 55TH DENTAL SQUADRON 2501 CAPEHART ROAD
APO AA
68113-5455
US

IV. Provider business mailing address

OFFUTT AFB 55TH DENTAL SQUADRON 2501 CAPEHART ROAD
APO AA
68113-5455
US

V. Phone/Fax

Practice location:
  • Phone: 402-232-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13679
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: