Healthcare Provider Details

I. General information

NPI: 1003506478
Provider Name (Legal Business Name): TIERNEY MAGILL KRISTOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 MAIN AVE
NORWALK CT
06851-1189
US

IV. Provider business mailing address

219 BENNETTS FARM RD
RIDGEFIELD CT
06877-1522
US

V. Phone/Fax

Practice location:
  • Phone: 203-854-5458
  • Fax:
Mailing address:
  • Phone: 847-764-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13958
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: