Healthcare Provider Details

I. General information

NPI: 1710962626
Provider Name (Legal Business Name): KRISTA COLLEEN IRWIN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMP CASEY DC 618TH DC (AS) UNIT # 15658
APO AP
96224-5658
KR

IV. Provider business mailing address

1 WARREN ST APT 206
CHARLESTOWN MA
02129-3621
US

V. Phone/Fax

Practice location:
  • Phone: 01031356980
  • Fax:
Mailing address:
  • Phone: 617-610-6980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number21136
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: