=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104016344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINE DONNELLY D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2007
-----------------------------------------------------
Last Update Date | 09/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2510 S TEXAS AVE
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-704-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 SW MILITARY DR
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78221-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-922-3483
-----------------------------------------------------
Fax | 210-927-4975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 25239
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------