Healthcare Provider Details

I. General information

NPI: 1891355814
Provider Name (Legal Business Name): DR. KRISTOPHER ANTONIO YEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 KATHRYN DR
BRIDGEPORT CT
06610-1264
US

IV. Provider business mailing address

32 KATHRYN DR
BRIDGEPORT CT
06610-1264
US

V. Phone/Fax

Practice location:
  • Phone: 203-243-9237
  • Fax:
Mailing address:
  • Phone: 203-243-9237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1858401
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: